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RC46  .C1 1  Golden  rules  of  diag 


Columbia  Mni\itx^itp 
in  tije  Citp  of  J^eto  ^orfe 

College  of  Plipgitiang  antJ  ^urgeon^ 


#tben  bp 

i^lt^g;  #ttiggie  €llis«on 

in  mcmorp  of 
r.  Crnegt  l®illiam  !lu?al 

1918 


GOLDEN  RULES 

OF 

DIAGNOSIS    AND    TREATMENT 
OF  DISEASES 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

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MEDICAL  GUIDE  AND  MONOGRAPH  SERIES 

GOLDEN  EULES 

OF 

DIAGNOSIS  AND  TKEATMENT 
OF  DISEASES 


APHORISMS,  OBSERVATIONS,  AND    PRECEPTS    ON  THE 

METHOD    OF   EXAMINATION  AND  DIAGNOSIS  OF 

DISEASES,  WITH    PRACTICAL   RULES  FOR 

PROPER    REMEDIAL    PROCEDURE. 


BY 

HENRY  A.  CABLES,  B.  S.,  M.  D. 

PROFESSOR  OF  MEDICINE    AND    CLINICAL    JIEDICINE  OF  THE    COLLEGE  OF  PHYSI- 
CIANS AND  SURGEONS,   ST.   LOUIS;    CONSULTANT  AT  JEFFERSON    HOSPITAL, 
ST.    LOUIS;      FORMERLY    HOUSE    PHYSICIAN    AT    ALEXIAN    BROTHERS* 
HOSPITAL,      ST.    LOUIS;    MEMBER    OF    THE    AMERICAN    MEDICAL 
ASSOCIATION,     ILLINOIS      STATE     MEDICAL     SOCIETY,     ETC. 


ST.  LOLnS 

C.  V.  MOSBY  COMPANY 

1911 


COPTBIGHT,   1911,  BY  C.   V.  MOSBY  COMPANT 


Preaa  of 

C.  V.  Mosby  Company 

St.  Louis 


PREFACE. 

Extensive  treatises  have  been  written  on  the 
diagnosis  and  treatment  of  diseases,  the  number  of 
the  diseases  considered  and  the  character  of  their 
description  varying  in  the  various  volumes  devoted 
to  these  subjects.  While  these  treatises  serve  their 
purpose,  there  are  many  urgent  instances  when  the 
physician  needs  a  book  of  ready  reference  of  diag- 
nosis, treatment,  and  remedial  procedure.  To  meet 
this  condition,  and  to  assist  the  busy  physician  and 
the  progressive  student  in  obtaining  the  needed 
information  readily  and  authentically,  this  book 
has  been  prepared. 

This  book  is  an  epitome  of  a  careful  and  exten- 
sive examination  of  the  literature  on  the  subjects 
considered,  supplemented  by  the  author's  experience 
in  private  and  hospital  practice,  and  the  method  of 
compilation  and  manner  of  presentation  of  demon- 
strated facts  have  been  found  to  be  the  best  for 
the  purpose  in  view.  Importance  has  been  attached 
to  the  clinical  methods  of  diagnosis,  but  at  the 
same  time  the  author  feels  that  the  laboratory  has 
been  drawn  upon  as  often  as  necessary,  as  a  phy- 
sician who  attempts  to  make  all  diagnoses  by  the 
laboratory  route  will  find  the  way  fraught  with 
tedium  and  uncertainty. 

The  suggestions  for  treatment  have  been  gleaned 
from  authoritative  current  literature  and  standard 


6  PREFACE. 

works.  A  variety  of  drugs  have  been  named  under 
some  of  the  subjects,  as  the  author  believes  that 
some  good  can  be  accomplished  by  correct  medi- 
cation. In  many  cases  there  is,  on  the  part  of  the 
physician,  a  lack  of  knowledge  of  proper  thera- 
peutic technic,  and  the  haphazard  way  of  treat- 
ment is  to  be  deprecated.  The  clinical  aspect  of 
the  individual  case  should  be  studied,  and  treat- 
ment followed  accordingly.  Too  often  a  physician 
administers  to  the  patient  the  first  cardiac  stimu- 
lant that  occurs  to  him,  regardless  of  the  fact  that 
such  a  stimulant  in  the  particular  case  is  extremely 
dangerous.  To  exemplify  another  condition,  it  can 
be  said  that  quinin  is  an  exceedingly  useful  friend 
in  small  doses  in  certain  affections,  because  of  its 
power  of  increasing  or  calling  out  the  body  de- 
fenses, but  in  large  oft-repeated  doses  it  will  have 
a  disastrous  effect,  causing  paralysis  of  the  body 
defense  by  destroying  the  ameboid  functions  of 
the  cells. 

This  book  is  presented  with  a  firm  belief  that  a 
study  of  it  will  assist  in  making  a  correct  diag- 
nosis, indicate  the  proper  therapeutic  procedure, 
and  aid  in  fixing  in  the  mind  valuable  information 
that  can  be  readily  recalled  when  needed. 

Henry  A.  Cables. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Diseases  of  the  Stomach 9 

Gastric  Ulcer,  9;  Gastric  Cancer,  15;  Gastritis,  18;  Hyper- 
chlorhydria,  22;   Hematemesis,  24. 

CHAPTER  II. 

Diseases  of  the  Intestines .26 

Acute  Enteritis,  26:  Chronic  Enteritis,  30;  Obstruction  of 
the  Bowel,  32;  Chronic  Constipation,  34;  Appendicitis,  37; 
Mucous  Colitis,  40;  Viceroptosis,  41. 

CHAPTER  III. 

Diseases  of  the  Lives 45 

Icterus  (Jaundice),  45;  Portal  Cirrhosis  (Lsennec's  Cir- 
rhosis, Alcoholic  Cirrhosis),  47;  Biliary  Cirrhosis,  51; 
Abscess  of  the  Liver,  52;  Acute  Yellow  Atrophy,  54; 
Cancer  of  the  Liver,  55. 

CHAPTER  IV. 

DiSIiASES    OF    THE    GaIXBLADDEE 67 

Gallstones,  57;    Suppurative   Cholangeitis,  60. 

CHAPTER  V. 

Diseases  of  the  Pancreas  and  Peeitonetjm: 62 

Hemorrhage,  62;  Acute  Pancreatitis,  63;  Chronic  Pancrea- 
titis, 64 ;  Pancreatic  Cysts,  65 ;  Carcinoma  of  the  Pancreas, 
66;  Acute  Peritonitis,  68. 

CHAPTER  VI. 

Diseases  of  the  Kidneys  and  Bladdee 71 

Movable  Kidney,  71;  Acute  Nephritis,  73;  Chronic  Paren- 
chymatous Nephritis,  78;  Chronic  Interstitial  Nephritis, 
81;  Uremia,  84;  Pyelitis,  89;  Hydronephrosis,  91;  Nephro- 
lithiasis, 92;  Cystitis,  98. 


8  CONTENTS. 

CHAPTER  VII. 

PAGE 

Diseases  of  the  Blood 102 

Chlorosis,  102;  Pernicious  Anemia,  106;  Leukemia,  108; 
Pseudoleukemia    (Hodgkin's  Disease),  110;  Purpura,  113. 

CHAPTER  VIII. 

Diseases  of  the  Ductless  Glands  .     .     . 116 

Addison's  Disease,  116;  Exophthalmic  Goiter,  118;  Myx- 
edema, 123. 

CHAPTER  IX. 

Diseases  of  the  Vasculae  System 127 

Pericarditis,  127;  Acute  Endocarditis,  132;  Malignant  Endo- 
carditis, 132;  Valvular  Disease  of  the  Heart,  135;  Palpita- 
tion, 152;  Angina  Pectoris,  154;  Arteriosclerosis,  158. 

CHAPTER  X. 

Diseases  of  the  Lu>'gs  a:xd  Pletjeae 163 

Acute  Bronchitis,  163;  Chronic  Bronchitis^  167;  Bronchi- 
ectasis, 172;  Bronchial  Asthma,  175;  Edema  of  the  Lungs, 
179;  Lobar  Pneumonia,  181;  Broncho-Pneumonia  (Lobu- 
lar Pneumonia),  190;  Chronic  Interstitial  Pneumonia, 
194;  Emphysema,  196;  Pulmonary  Gangrene,  197;  Pul- 
monary Tuberculosis,  199;   Acute  Pleurisy,  211. 

CHAPTER  XL 

Infectious   Diseases 216 

Typhoid  (Enteric  Fever),  216;  Bacillary  Dysentery,  227; 
Amebi(?  Dysentery,  231;  Measles^  233;  Scarlet  Fever 
(Scarlatina),  236;  Malaria,  243;  Diphtheria,  251;  Rheu- 
matic Fever    (Inflammatory  Rheumatism),  255. 

CHAPTER  XIL 

Constitutional  Diseases 280 

Arthritis  Deformans,  260;  Gout,  263;  Diabetes  Mellitus,  267 

CHAPTER  XIII. 

GENEBAL    CoNSIDEEATIONS r.      >:      i.i       .       >       .        .    272 

Physician  and  Patient,  272, 


GOLDEN  EULES 

OF 

DIAGNOSIS  AND  TREATMENT 
OF  DISEASES. 


CHAPTER  I. 

DISEASES  OF  THE  STOMACH. 

Gastric  Ulcer. 

Eemember  that,  while  the  tripod  pain,  vomiting, 
and  hematemesis  are  somewhat  characteristic  of 
peptic  ulcer,  they  possess  certain  peculiarities. 
The  pain  of  ulcer  is  localized  in  a  circumscribed 
area  in  the  epigastrium,  and  radiates  to  the  back  at 
about  the  tenth  dorsal  vertebra.  Tenderness  is 
found  over  the  area  of  pain. 

Remember  that  the  pain  occurs  paroxysmally 
when  food  is  taken  and  digestion  is  at  its  height, 
produced  by  irritation  of  acid  gastric  juice  and  the 
peristalsis. 

Emptying  the  stomach,  either  by  vomiting  or  with 
stomach  tube,  relieves  pain.  Many  patients  will 
produce  emesis  to  get  relief. 

Eemember  that  vomiting  is  rarely  absent  and  oc- 
curs at  the  height  of  pain;  and  when  the  stomach  is 
emptied,  vomiting  ceases  and  the  pain  is  relieved. 

9 


10  DISEASES    OF    THE    STOMACH. 

Hydrochloric  acid  is  always  present  in  vomitus  of 
nicer,  and  frequently  is  excessive. 

Remember  that  copious,  free  hemorrhage  is  far 
more  common  in  ulcer  than  in  any  other  disease  of 
the  stomach. 

Remember  that  profuse,  painless,  sudden  hema- 
temesis  in  an  elderly  patient  suggests  hepatic 
cirrhosis  rather  than  gastric  ulcer. 

Dilatation  occurs  after  the  ulcer  heals.  It  occurs 
only  when  the  ulcer  is  near  the  pyloric  opening  and 
the  contracting  scar  tissue  partially  closes  it. 

Don't  mistake  the  anemia  of  ulcer  for  malignant 
cachexia. 

Remember  that  the  vomiting  of  bright-red  blood 
is  almost  positive  evidence  of  ulcer. 

Remember  that  the  first  symptom  of  ulcer  may  be 
perforation  or  a  fatal  hemorrhage. 

The  area  of  tenderness  in  ulcer  is  about  two 
inches  below  the  ensiform  cartilage  and  a  little  to 
the  right  of  the  median  line. 

Remember  that  the  pain  of  ulcer  may  be  referred 
to  the  lower  intercostal  nerves,  or  axillary  plexus, 
or  down  the  arm. 

Pain  may  persist  after  the  ulcer  heals,  caused  by 
nerve  filaments  being  caught  and  compressed  in 
contracting  and  hardening  of  the  scar  tissue. 

Remember  that  ulcer  is  twice  as  frequent  in 
women,  and  occurs  between  the  fifteenth  and 
twenty -fifth  years. 

Remember  that  the  pain  of  gastralgia  is  diffuse. 


GASTRIC    ULCEE.  11 

and  pressure  or  food  relieves  it,  and  neither  hema- 
temesis  nor  anemia  occur. 

Remember  that  in  the  pain  of  gallstones  the  liver 
is  enlarged  and  tender,  and  that  jaundice  and  pal- 
pable gallbladder  is  frequently  present. 

Always  examine  the  stools,  as  frequently  they 
contain  blood,  either  macroscopic  or  occult,  when 
the  vomitus  does  not. 

Remember  that  the  appetite  is  good  in  ulcer,  but 
vomiting  prevents  digestion  and  nutrition  is  re- 
duced; hence  these  patients  lose  in  weight. 

Remember  that  perforation  is  announced  by  sud- 
den, sharp,  lancinating  pain;  weak,  rapid  pulse; 
shallow,  hurried  breathing,  and  cold,  clammy  sweat, 
with  muscular  rigidity  and  tenderness  over  the  ab- 
domen. 

Remember  that  surgery  is  imperatively  indicated 
in  the  early  hours  of  perforation,  before  peritonitis 
develops.  It  is  the  importance  of  early  surgical  in- 
tervention that  demands  careful  watchfulness  on 
the  part  of  the  physician.  It  is  gross  ignorance  or 
criminal  carelessness  to  wait  until  peritonitis  begins. 

Remember  that  passing  a  stomach  tube  may  cause 
rupture  at  site  of  ulcer. 

Treatment. 

Remember  that  there  must  be  mechanical  as  well 
as  functional  rest  of  the  stomach,  and  the  only  way 
to  obtain  it  is  to  keep  the  patient  in  bed. 

Remember  that  thirty-six  hours  of  fasting,  ex- 


12  DISEASES    OF    THE    STOMACH. 

eluding  even  water,  is  the  very  best  way  to  begin 
the  treatment,  unless  the  patient  is  greatly  ema- 
ciated or  old. 
Eelieve  thirst  with  salt  solution  enemata. 
Begin  rectal  feeding  at  the  end  of  thirty-six  hours. 
Nutrient  enamata  during  the  fasting  period  will 
stimulate  reflexly  the  gastric  secretion,  and  this  will 
irritate  the  ulcer  and  cause  pain. 

Remember  that  the  rectum  has  no  digesting 
power;  hence  all  foods  must  be  ready  for  absorption. 
Predigested  milk,  to  which  is  added  one  raw  egg, 
makes  an  excellent  enema.  Don't  give  too  large  a 
quantity  at  a  time,  or  it  will  be  expelled.  Four 
ounces,  repeated  every  four  hours,  is  best. 

Remember  that  panopepton  is  excellent  in  rectal 
feeding.  Add  it  to  normal  salt  solution.  It  is  also 
excellent  to  begin  feeding  by  mouth. 

Don't  feed  per  rectum  too  long,  as  the  bowel  be- 
comes irritated  and  will  not  retain  the  enema.  Feed 
per  rectum  exclusively  for  five  days  and  then  give 
some  food  by  mouth.  Two  ounces  of  milk  every 
three  hours,  with  careful  watching  for  return  of 
pain,  and,  when  absent,  gradually  increase  the 
amount,  is  a  good  plan.  At  the  end  of  the  second 
week  add  meat  broth,  mashed  potatoes,  and  white 
meat  of  fowl. 

The  medicinal  treatment  is  important,  but  not  so 
effective  when  the  dietetic  regimen  is  omitted. 

The  following  prescription  and  method  of  admin- 
istering it  give  good  results: 


GASTRIC    ULCER  13 

IJ     Bismuthi  subnitratis   3  ij-3  v 

Aquae B  i  j 

Misce. 

Sig. :  Give  at  one  dose,  with  patient  in  the  recumbent 
posture.  Have  the  patient  move  from  dorsal  to  side  posi- 
tion slowly,  then  to  the  other  side,  thus  allowing  the  bis- 
muth to  coat  the  mucosa. 

Or: 

R     Cerrii  oxalatis    gr.  i j 

Magnesii  carbonatis  levis gr.  x 

Bismuthi  subcarbonatis    gr.  xx 

Misce  et  fiat  pulvere  No.  I. 

Sig.:  Powder  from  three  to  six  times  daily. 

Iron  may  be  added  to  the  above  if  anemia  be  se- 
vere.   This  will  relieve  vomiting  and  is  antacid. 

Or: 

Tfi     Relbrcinolis    (Merck)    3  j 

Argenti  nitratis    gr.  vj 

Extracti  hyoscyaminge  gr.  xxx 

Misce  et  fiant  pilulse  No.  XXIV. 

Sig.:   Pill  three  times  daily  one  hour  before  meals. 

Astringent,  antiseptic,  and  relieves  pain. 
Or: 

IJ     Argenti  nitratis    gr.  vj 

Extracti   belladonnas    gr.  v 

Extracti   hyoscyaminse    gr.  xx 

Extracti  gentianae    q.  s. 

Misce  et  fiant  pilulae  No.  XXIV. 

Sig. :  Pill  one  hour  before  meals. 

This  is  an  excellent  combination — astringent  and 
tonic. 

Silver  nitrate  may  be  given  in  solution,  either 
gr.  ^  or  solution  1 :1000  can  be  made  and  gradually 
increase  dosage.    Ortner's  prescription  is  good. 


14  DISEASES    OF   THE    STOMACH. 

IJ     Extract!  belladonnae    gr.  viiss 

Bismuthi  subnitratis, 
■     Magnesii  oxidi, 

Sodii  bicarbonatis    aa  3  iiss 

Misce  et  fiant  pulveres. 

Sig. :  A  good  pincb  three  times  daily  after  eating.  (Ortner.) 

For  liematemesis,  complete  rest,  and  be^t  obtained 
by  hypodermic  of  morphin  and  atropin.  Ice  bag 
to  epigastrium.  If  severe,  bandage  extremities  and 
raise  foot  of  bed.  Replace  lost  fluid  with  normal 
salt  solution,  either  in  rectum  or  into  cellular  tissue, 
by  hypodermoclysis. 

Ortner  now  gives  10  drams  hypodermatically  of 
Merck's  10-percent  gelatin  solution  as  long  as  blood 
may  be  seen  in  vomitus  or  stools.  , 

Tincture  of  the  chloride  of  iron  5  to  15  drops  every 
two  hours  is  recommended. 

IJ     Stypticini    (Merck)    gr.  x 

Antipyrini    gr.  xl 

Elixiris  simplicis   5  j 

Misce  et  fiat  solutio. 

Sig.:   Teaspoonful  in  water  every  two  or  three  hours  as 
needed. 

Or: 

I^     Aeidi  tannici  3  ij 

Pulveres   aluminis    3  j 

Garantose     gr.  ss 

Misce  et  fiant  pulveres  No.  XVI. 

Sig. :  2  powders  every  fifteen  minutes,  followed  by  water. 

Where  the  cicatricial  tissue  causes  obstruction  at 
the  pylorus,  thiosinamin  may  be  used  to  cause  ab- 
sorption. 


GASTRIC   ULCER GASTRIC   CANCER.  15 

IJ     Thiosinamini 3  j 

Glycerini     3  ii j 

Alcoholis  diluti 3  vj 

Misce  et  fiat  solutio. 

Sig. :  Inject  8  to  15  minims  subcutaneously  every  two  or 
three  days. 

Gastric  Cancer. 

Remember  that  cancer  of  the  stomach  is  on  the 
increase.  A  large  majority  of  the  cases  occur  be- 
tween the  fortieth  and  seventieth  years,  but  it  is  fre- 
quently found  in  young  adults  and  even  children. 

Remember  that  enlarged  and  painless  cervical  or 
inguinal  lymph  glands  found  in  a  dyspeptic  past 
midlife  strongly  indicate  cancer. 

Nodular  swellings  found  under  the  skin  about  the 
navel  or  between  it  and  the  costal  arch  are  meta- 
static cancer  growths. 

Remember  that  many  cancer  patients  have  edema 
about  the  ankles  or  anasarca.  This  condition  de- 
velops toward  the  close  and  is  due  to  debility. 

In  cancer  the  vomiting  frequently  occurs  late  in 
the  day  or  during  the  night,  with  insomnia.  Fre- 
quently insomnia  is  the  most  troublesome  symptom. 

Remember  that  a  tumor  can  be  palpated  in  three- 
fourths  of  the  cases. 

Remember  that  a  gastric  tumor  can  be  moved  to 
any  part  of  the  abdomen,  or  even  into  the  pelvis. 

Remember  that  a  tumor  that  moves  with  respira- 
tion, but  has  neither  respiratory  fixation  nor  lateral 
movements,  is  not  gastric,  but  hepatic. 

Remember  that  hydrochloric  acid  is  absent  or 


16  DISEASES    OF    THE    STOMACH. 

greatly  diminished,  and  lactic  acid  is  present  and 
Boas-Oppler  bacillus  may  be  found. 

Always  examine  gastric  contents,  and  better  give 
test  meal. 

Remember  tliat  in  palpating  a  gastric  tumor  three 
tilings  are  found: 

1.  Changes  on  deep  inspiration,  but  is  free  from 
respiratory  movements. 

2.  Wide  area  of  aortic  pulsation. 

3.  Intrinsic  movements  occurring  in  the  contrac- 
tion of  the  hypertrophied  muscularis  of  the  tumor, 
causing  it  to  appear  and  disappear,  lifting  the  ab- 
dominal wall  overlying  the  tumor. 

Remember  the  value  of  inspection  and  observe — 

1.  The  state  of  general  nutrition. 

2.  Fullness  in  the  epigastrium. 

3.  Peristaltic  waves. 

4.  Nodules  under  the  skin. 

Remember  that  the  pain  of  carcinoma  is  constant 
and  gnawing,  not  often  referred,  and  vomiting  af- 
fords no  relief. 

Remember  that  fatty  stools,  uncontrollable 
diarrhea,  glycosuria,  and  perhaps  the  palpation  of 
an  immovable  tumor  are  signs  of  pancreatic  cancer. 

Remember  that  emaciation,  loss  of  weight  and 
strength,  vomiting  of  coffee-ground  colored  ma- 
terial, and  cachexia,  with  presence  of  gastric  tumor, 
leaves  little  doubt  of  cancer.  As  a  rule  there  is  no 
vomiting  of  bright-red  blood  or  clots,  that  are  fre- 
quently associated  with  peptic  ulcer. 


GASTRIC   CANCER.  17 

Remember  that  the  duration  is  short,  seldom  ex- 
ceeding one  year. 

Treatment. 

Surgery  offers  the  only  hope,  and  the  diagnosis 
must  be  made  early  if  an  operation  be  of  any  benefit. 

Remember  that,  medicinally,  the  object  sought  is 
relief  of  pain  and  vomiting.    Tonics  should  be  given. 

Washing  out  the  stomach  often  relieves  pain  and 
vomiting.  Use  saline  solution  or  boracic  acid  solu- 
tion. Condurango  bark,  given  in  powder  of  30 
grains  each  three  times  daily,  gives  excellent  re- 
sults as  to  the  amelioration  of  symptoms  and  im- 
provement of  appetite. 

Elixiris  ferri  quininae  et  strychninae  (U.  S.  P.) 
o  ij,  three  times  daily  after  meals. 

Liquoris  potassii  arsenitis  ill  iij  vel  nrt  v  is  not 
only  a  good  tonic,  but  is  very  beneficial  in  fighting 
the  anemia. 

Where  pain  is  due  to  superacidity,  the  following 
relieves  by  neutralizing  the  acid: 

IJ     Sodii  bicarbonatis    gr.  xv  vel  gr.  xx 

Magnesii  carbonatis  gr.  v  vel  gr.  x 

Acidi  hydrocyanici  diluti   TTl  iv 

Aquae  mentlias  piperitse    .  .  .  .  q.  s.  ad  g  j 

Misce. 

Sig. :    To  be  taken  at  one  dose  and  repeat   three    times 
daily. 

Creosote  in  minim  doses  in  gelatin  capsule  after 
food  is  very  highly  praised  by  Yeo.  He  says  espe- 
cially good  results  are  obtained  in  the  scirrhus  form 
of  cancer. 


18  DISEASES   OF   THE    STOMACH. 

IJ     Dionini gr.  vii j 

Acidi  hydrocyanici  diluti    TTL  xxx 

Bismuthi  subnitratis   3  ij 

Aquae    chloroformi     q.  s.  ad  5  iv 

Misce  et  fiat  solutio. 

Sig. :   Shake  well  and  take  teaspoonful  every  two  or  three 
hours. 

Or: 

IJ     Resorcinolis    ( Merck )    gr.  xxx 

Vini  rhei   3  j 

Syrupi  aurantii 3  iv 

Decoctionis  condurango  ( 1 :  12 )  q.  s.  ad  5  vj 
Misce  et  fiat  solutio.    Dispense  in  dark  amber  bottles. 
Sig. :  Tablespoonful  every  two  hours. 

Gastritis. 

Remember  that  the  history  of  the  case,  especially 
that  relating  to  the  diet,  will  be  of  great  help  in 
diagnosis.  Usually  find  excess  at  the  table,  the  eat- 
ing of  tainted  food  or  overripe  fruit. 

Remember  that  a  majority  of  the  cases  are 
afebrile,  and  recovery  in  forty-eight  hours  is  the 
rule,  except  where  the  attack  is  due  to  toxic  sub- 
stances contained  in  the  food. 

Always  test  the  knee  jerk  and  reaction  of  the 
pupil,  because  gastric  crisis  occurring  in  locomotor 
ataxia  frequently  simulates  acute  gastritis. 

Remember  that  a  severe  case  may  require  time  to 
clear  up  the  diagnosis.  For  instance,  an  attack  ac- 
companied by  severe  headache  and  delirium  occur- 
ring in  a  child  might  be  mistaken  for  meningitis,  or 
the  pain  may  be  so  severe  as  to  suggest  gallstones, 
and  frequently  it  marks  the  onset  of  many  of  the 


GASTRITIS. 


19 


infectious  diseases,  as  measles,  scarlatina,  and  ty- 
phoid. 

Always  examine  the  heart,  liver,  and  lungs  in  all 
cases  of  chronic  gastric  catarrh,  as  it  is  often  due 
to  portal  stasis. 

Remember  that  the  vomiting  of  mucus,  or  where 
the  gastric  contents  are  thickly  coated  with  mucus, 
is  found  only  in  catarrhal  processes. 

Remember  that  alcohol  is  an  important  factor  in 
causing  chronic  gastritis,  and  it  must  be  discon- 
tinued if  treatment  be  of  any  avail. 

Many  cases  of  cardiac  palpitation  or  dyspnea  are 
due  to  gastritis,  causing  the  food  to  ferment  and  the 
gas  distends  the  stomach. 

Treatment. 

In  an  acute  attack  allow  no  food  for  twenty-four 
hours.  Stimulate  vomiting  by  giving  a  tumbler  of 
warm  salt  water  and  repeat  until  the  stomach  is 
thoroughly  cleansed.  If  water  checks  the  vomiting 
by  diluting  the  irritant,  produce  it  by  tickling  the 
fauces.  Use  the  stomach  tube  if  possible  and  wash 
out  thoroughly.    Follow  with  a  cathartic. 

Olei  recini  qJ,  given  in  orange  juice,  with  2  or 
3  drops  of  tincturse  opii  if  needed,  is  excellent. 

If  icterus  develops,  or  vomiting  persists,  give  the 
following : 

3     Hydrargyri  chloridi  mitis gr.  iv 

Cerrii  oxalitis   gr.  x 

Sacchari  lactis    gr.  xxx 

Misce  et  fiant  pulveres  No.  XII. 

Sig. :   Powder  dry  on  tongue  every  fifteen  minutes. 


20  DISEASES    OF   THE    STOMACH. 

Two  hours  after  last  powder  give  saline.  A  mus- 
tard plaster  over  the  epigastrium  gives  relief. 

For  continued  nausea  allow  cracked  ice.  Follow 
with  a  liquid  diet,  preferably  milk,  to  which  add 
lime  water  or  soda  water.  Allow  a  wineglassful 
every  three  or  four  hours.  After  cleansing  the 
stomach  a  sedative  is  indicated  and  bismuth  is  the 
best. 

IJ     Bismuthi  carbonatis, 

Sodii  bicarbonatis   aa  3  i j 

Spiritus  chloroformi    3  j 

Aquae  menthae  piperitse    ....  q.  s.  ad  5  iij 
Misce  et  fiat  solutio. 
Sig. :  Tablespoonful  every  four  hours. 

If  the  pain  is  severe,  the  deodorized  tincture  of 
opium  may  be  added  to  the  above.  Later  a  bitter 
tonic  may  be  needed.    The  following  is  good: 

IJ     Tincturae  nucis  vomicae 3  ij 

Tincturae  gentianae  compositae   5  iss 

Tincturae  cinchonae  compositae  q.  s.  ad  ^  iv 
Misce  et  fiat  solutio. 
Sig.:  Teaspoonful  before  meals. 

Dilute  muriatic  or  nitromuriatic  acid  may  be 
added  if  needed.  In  chronic  cases  remove  the  cause, 
if  possible.  If  due  to  alcohol  or  iced  drinks,  prohibit 
them.  If  secondary  to  cardiac,  hepatic,  or  pul- 
monary conditions,  relief  will  follow  improvement 
in  those  conditions.  It  is  in  the  chronic  form  that 
stomach  washing  gives  the  most  brilliant  results. 

After  a  thorough  washing  with  clear  water,  the 
following  solution  may  be  run  into  the  stomach  as 
a  final  douche: 


GASTRITIS.  21 

IJ     Thymol   gr.  viij 

Acidi  borici   3  iv 

Aquae O  j 

Misce  et  fiat  solutio. 

Sig. :  Use  in  stomach  tube. 

If  the  tube  can  not  be  used,  have  the  patient 
drink  a  pint  of  hot  water  in  which  is  dissolved  a 
half  dram  of  sodium  bicarbonate  on  arising  in  the 
morning.  This  will  dissolve  the  mucus,  and  thus 
cleanse  the  gastric  mucosa  as  well  as  stimulate  the 
circulation.  Direct  patient  to  take  meal  without 
liquids.  This  insures  thorough  mastication  and  in- 
salivation.  Diet  should  be  light  and  nutritious.  A 
glass  of  milk  containing  a  raw  egg,  given  twice  a 
day  between  meals,  is  excellent.  If  dilatation  exists, 
give  dry  diet  and  small  quantity  every  four  hours, 
and  wash  out  stomach  once  a  day. 

For  sour  eructations  and  distention  of  stomach  by 
gas  the  following  is  excellent: 

B     Phenolis    gr.  xxv 

Glyeerini    3  iv 

Bismuthi  subcarbonatis    3  v 

Lactis  magnesise    q.  s.  ad  3  iij 

Misce. 

Sig.:   Shake  well  and  take  teaspoonful  after  food. 

The  following  before  meals  gives  good  results : 

3     Resorcinolis    ( Merck )    3  j 

Bismuthi  salicylatis  3  iiss 

Tincturse  catechu   3  vj 

Syrupi  aurantii §  i j 

Aquae    q.  s.  ad  5  iv 

Misce. 

Sig.:    Shake  and  take  dessertspoonful  half    hour    before 
meals. 


22  DISEASES   OF    THE    STOMACH. 

Where  neurasthenia  coexists : 

R     Arseni  trioxidi    gr.  j 

Extracti  nucis  vomicse gr.  x 

Euquinini    (Merck)    gr.  xxx 

Ferri  carbonatis   3  ij 

Mucilaginis  acaciee   q.  s. 

Misce  et  fiant  pilulae  No.  LX. 
Sig. :   2  pills  after  meals. 

Hyperchlorhydria. 

Remember  that  under  this  term  is  included  a  con- 
dition of  excessive  formation  of  hydrochloric  acid, 
due  entirely  to  nervous  influence,  and  no  anatomical 
lesion  is  found;  hence  it  is  quite  common  in  chloro- 
sis, hysteria,  and  neurasthenia.  It  is  frequently 
found  in  brainworkers. 

Pain  is  variable,  from  mild  discomfort  after  meals 
to  an  intense  gastralgia,  developing  at  the  height 
of  digestion  and  caused  by  the  presence  of  free 
hydrochloric  acid.  Vomiting  or  eating  of  proteid 
food  will  relieve  the  pain,  because  it  removes  the 
acid. 

Eructation,  heartburn,  increased  salivation,  and 
vomiting  of  sour  liquid  occurs. 

Remember  that  there  is  no  "tender  spot"  or 
hematemesis  as  seen  in  ulcer. 

Remember  that  the  absence  of  excess  of  mucus 
and  excess  of  HCl  with  the  history  excludes  gas- 
tritis. 

Examination  of  stomach  contents  shows  HCl,  no 
lactic  acid  or  Oppler-Boas  bacilli,  and  the  duration 
of  disease  will  exclude  cancer. 


HYPERCHLORHYDRIA.  23 

Remember  that  this  condition  occurs  in  children, 
and  usually  presents  the  following  picture :  a  highly 
neurotic  child  is  attacked  at  midday  by  severe  head- 
ache, causing  it  to  cry  out  with  pain,  increased  by 
moving  the  head,  or  by  coughing  or  sneezing;  next 
a  violent  pain  in  the  stomach,  with  legs  drawn  up, 
hands  clasped  over  the  stomach;  belching  of  gas 
and  sudden  emesis,  without  apparent  effort,  which 
gives  relief.  The  vomitus  is  pale-green  or  yellow 
color,  fluid,  and  contains  an  excess  of  HCl.  It  will 
digest  egg  albumen.  Usually  a  rise  of  temperature 
at  onset,  but  later  becomes  subnormal.  Tongue  is 
clear,  moist,  and  red. 

Treatment. 

Diet.  Milk  and  egg  diet  for  a  few  days  often 
relieves  milder  forms.  Proteid  diet  is  indicated,  as 
it  uses  up  the  acid.  Carbohydrates  should  be  greatly 
restricted.  Don't  allow  wines,  liquors,  tobacco,  con- 
diments, smoked  meat,  sour  foods,  or  radishes. 

Lavage.  Washing  out  the  stomach,  preferably 
in  the  evening,  with  an  alkaline  solution  or  a  solu- 
tion of  silver  nitrate  (1:1000)  gives  excellent  results. 

Medication.  Alkalies,  especially  the  earthy,  are 
indicated. 

The  following  is  a  good  antacid: 

IJ     Sodii  carbonatis, 

Magnesii  carbonatis, 

Bismuthi  subcarbonatis   aa  gr.  xv 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  No.  XX. 
Sig. :  Powder  two  or  three  hours  after  meals. 


24  DISEASES    OF    THE    STOMACH. 

To  check  secretion  use  belladonna  or  atropin: 

IJ.     Extract!  belladonnse  g^-Vs 

Magnesii  oxidi    gr.  x 

Misce  et  fiat  pulvere  Xo.  I.     Dentur  tales  No.  XX. 
Sig. :  Powder  after  meals. 

If  fermentation  occurs,  witli  eructation  of  gas: 

I^     Phenolis    •  •  gr.  xxv 

Glycerin!    3  i j 

Bismuthi   subcarbonatis    3  iv 

Lactis  magnesise    q.  s.  ad  §  iij 

Misce  et  fiat  solutio. 

Sig. :  Shake  well  and  take  a  teaspoonful  after  meals. 

Or: 

IJ.     Argenti  nitratis    gr.  iij 

Aquse  destillatae    §  iij 

Misce  et  fiat  solutio. 

Sig.:  Dessertspoonful  two  hours  after  meals. 

Distress  after  meals  may  be  relieved  by: 

'  IJ.     Creosoti     TT],  sv 

Sodii  bicarbonatis    gr.  xxx 

Spiritus  chloroformi, 
Spiritus  ammonii  aromatici   .  .  .  .  aa  3  ss 
AquEB  menthse  piperitse    ....  q.  s.  ad  §  iij 
Misce  et  fiat  solutio. 
Sig.:   Dessertspoonful  after  meals. 

For  the  nervousness  give: 

IJ     Sodii  bromidi    3  j 

Resoreinolis    ( Merck )    gr.  xxv 

Aquse  anisi   q.  s.  ad  §  iij 

Misce  et  fiat  solutio. 

Sig.:   Dessertspoonful  after  meals. 

Hematemesis. 

Remember  that  fatal  syncope  may  occur  without 
any  vomiting.  The  blood  vomited  may  be  fluid  or 
clotted,  and  is  usually  dark  in  color.    Anemia  and 


HEMATEMESIS.  25 

edema  develop  early,  and  convulsions,  hemiplegia, 
or  blindness  may  occur. 

Remember  that  gastric  hemorrhage  may  be  the 
first  symptom  observed  in  leukemia. 

Remember  that  fatal  hemorrhage  may  be  due  to 
rupture  of  varix  in  esophagus,  and  blood  run  into 
the  stomach;  hence  no  gastric  lesion  is  found. 

Remember  that  the  blood  is  vomited  if  it  comes 
from  the  stomach,  while  it  comes  up  from  the  lungs 
after  a  fit  of  coughing;  as  a  rule,  blood  from  the 
lungs  is  free  of  clots,  or,  if  any,  they  are  small.  The 
blood  is  frothy,  because  of  the  contained  air  and 
alkaline  in  reaction. 

Tkeatment^ 

Absolute  quiet  in  bed.  Nothing  by  mouth,  except 
cracked  ice.  Morphin  and  atropin  hypodermatically 
to  effect.  Ergot  or  ergotin  hj^Dodermatically.  Give 
10  drams  of  Merck's  gelatin,  10-percent,  sterilized, 
and  repeat  as  long  as  blood  appears  in  vomit  or 
stools.  Ice  bag  over  epigastric  region.  Feed  only 
per  rectum. 

Tincturse  ferri  chloridi  in  5  to  15  drops  may  be 
given.  Plumbi  acetatis  gr.  ss-gr.  j  may  be  given 
every  two  hours.  If  severe  or  oft  repeated,  opera- 
tion is  indicated  if  the  patient's  condition  is  good. 

Most  cases  recover  quickly  with  rest,  and  st^iotics 
per  OS  may  cause  vomiting.  Hypodermoclysis  of 
normal  saline  solution  or  transfusion  by  Crile's 
method  may  be  life-saving. 


CHAPTEE  n. 
DISEASES  OF  THE  INTESTINES. 

Acute  Enteritis. 

Remember  that  exposure  to  cold  or  sudden  and 
decisive  drop  in  the  temperature  may  cause  an 
enteritis,  probably  due  to  influence  on  cutaneous 
nerves.  Improper  food,  especially  in  children,  is 
a  very  frequent  cause. 

There  is  no  question  that  some  cases  are  due  to 
malaria,  and  quinin  readily  controls  the  diarrhea 
when  other  remedies  fail. 

The  dominant  symptom  is  diarrhea.  The  stools 
are  thin,  mushy,  or  watery,  and  pale-yellow  or 
greenish  color,  and  contain  mucus,  but  rarely  any 
blood.  In  severe  form  stools  lose  color,  assume  the 
rice-water  character,  are  foamy,  and  have  sour  odor. 
With  the  microscope  portions  of  undigested  food, 
mucus,  bacteria,  epithelial  cells,  and  calcium  oxalate 
and  phosphate  crystals  may  be  seen. 

Colic  is  often  present.  The  severity  of  the  pain 
varies,  and  may  cause  collapse.  Pressure  over  the 
abdomen  affords  relief.  Abdominal  distention  and 
borborygmi  occur,  due  to  gas  formation.  Great 
thirst  and  diminution  of  quantity  of  urine  occur 
from  loss  of  water  by  the  bowel.  In  severe  cases 
urinary  suppression  occurs,  followed  by  general 
edema.     Albumins  and  casts  may  be  found  in  the 

26 


ACUTE    ENTERITIS.  27 

urine.  Skin  may  be  cyanotic,  cold,  and  clammy. 
Emaciation  is  rapid  in  children,  and  eyes  become 
sunken.  Fever  may  occur,  but  is  usually  absent. 
Remember  that,  in  case  fever  is  present,  it  lacks 
the  peculiar  curve  and  persistency  found  in  typhoid, 
and  the  absence  of  slow  pulse;  the  enlarged  spleen 
and  the  absence  of  eruption  would  also  exclude 
typhoid. 

Etiologic  Treatment. 

If  pain  be  severe,  give  hypodermic  of  morphin 
and  atropin.  If  due  to  cold,  give  sudorifics  and  ex- 
ternal applications  to  produce  sweating.  Where  ma- 
laria is  cause,  give  quinin.  If  due  to  chemical  poi- 
sons that  can  be  neutralized,  give  the  proper  anti- 
dote. 

If  caused  by  toxins  that  can  not  be  neutralized, 
too  coarse  food,  or  impacted  feces,  rid  the  bowel  as 
soon  as  possible  of  irritating  substances. 

Cathartics.  We  have  two  means  of  cleansing  the 
bowel — drugs  and  colon  irrigation.  Owing  to  the 
inflammatory  condition,  only  mild  drugs  should  be 
given.    Castor  oil  or  calomel  is  best. 

Castor  oil  should  be  administered  in  one  large 
dose,  ^  ounce  in  orange  juice,  to  which  may  be 
added  a  few  drops  of  tincture  of  opium  to  prevent 
griping. 

Calomel  is  especially  indicated  in  persistent 
vomiting.  Best  to  give  one  large  dose — gr.  iv-gr.  vij 
— as  small  repeated  doses  may  irritate  the  bowel. 


28  DISEASES   OF   THE    INTESTINES. 

Colon  irrigation  is  the  least  harmful.  Use  1  quart 
of  warm  water,  and,  to  assist  in  retaining  it,  add  20 
drops  of  the  tincture  of  opium.  Soap,  glycerin,  or 
oil  may  be  used  in  the  water. 

Diet  is  important.  Reduce  the  work  of  the  bowel 
to  the  minimum  by  using  concentrated  diet,  with 
little  residue.  Complete  abstinence  for  twenty-four 
hours,  with  teaspoonful  of  tea  for  the  thirst,  is  ex- 
cellent. Allow  only  gruels  from  barley,  rice,  sago, 
or  arrow-root.  Give  one  or  two  tablespoonfuls 
hourly.  Albumen  water  is  allowable.  Of  liquids, 
tea  is  best,  given  tepid  or  hot.  As  the  diarrhea 
decreases  give  broths,  with  yolk  of  egg,  crackers, 
and.  breadcrusts.  During  the  attack  give  food  in 
small  quantities,  neither  very  hot  nor  cold.  Milk 
may  be  tried  by  giving  a  tepid  tablespoonful  hourly, 
and,  if  it  increases  the  diarrhea,  stop  it. 

Medication  should  be  such  as  meets  the  indica- 
tions. Soft  capsule  of  olei  ricini  ttl  x-ttl  xx  and  salol 
gr.  V  are  very  efficacious.  Or  creosote  may  be  used  as 
follows : 

IJ     Creosoti     TTl,  xv 

Tincturse  gentianae  compositse TTt  xxx 

Spiritus  vini  gallici 3  iij 

Misce. 

Sig. :  Teaspoonful  three  times  daily. 

Or: 

I^     Bismuthi  benzoatis 3  ij 

Salolis     gr.  xxiv 

Pulveris  opii  gr.  vj 

Misce  et  fiant  pulveres  No.  VIII. 

Sig.:  Powder  every  three  or  four  hours  after    the    bowels 
have  first  been  cleansed  of  irritating  material. 


ACUTE   ENTERITIS.  29 

Or: 

IJ     Tannalbini 3  ij 

Resorcinolis    (Merck)    gr-  xv 

Glyeerini    §  j 

Aquse  cinnamomi q.  s.  ad  §  iv 

Misce  fiat  misturse. 

Sig. :  Shake  well  and  take  a  dessertspoonful  every  three 
hours.    For  adult  a  tablespoonful  should  be  given. 

For  relief  of  thirst  and  to  replace  the  fluid  lost 
by  the  body,  the  continual  seepage  of  normal  saline 
solution  into  the  bowel  is  excellent.  The  technic  of 
continuous  flow  is  very  important  and  is  as  follows: 
a  fountain  syringe,  or  a  can  with  a  large  rubber 
tube  attached,  and  a  hard-rubber  vaginal  tip,  with 
several  openings  at  the  end,  is  all  that  is  required. 
Flex  the  vaginal  tip  about  two  inches  from  the  end 
by  placing  it  in  hot  water  and  bending  it,  thus 
forming  an  obtuse  angle.  Insert  until  the  angle  fits 
closely  to  the  sphincter,  then  bind  the  tube  to  the 
thigh  with  strips  of  adhesive  to  prevent  its  being 
expelled.  The  douche  bag  or  can  is  suspended  from 
the  foot  of  the  bed  so  that  its  base  is  six  inches 
above  the  level  of  the  patient's  buttocks.  Put  one 
and  a  half  pints  of  solution  in  the  bag  at  a  tem- 
perature of  100°  and  keep  it  at  this  tempera- 
ture. It  should  require  no  less  than  forty  nor  more 
than  sixty  minutes  for  this  amount  to  percolate 
into  the  bowel.  If  administered  more  rapidly,  it 
will  be  expelled.  A  hypodermoclysis  of  normal  sa- 
line solution  into  the  subcutaneous  tissue  may  be 
resorted  to  in  desperate  cases. 


30  DISEASES    OF    THE    INTESTINES. 

Chronic  Enteritis. 

Remember  that  constipation  is  the  rule  in  the 
chronic,  but  may  alternate  with  diarrhea. 

Always  examine  the  stools,  as  they  contain  the 
diagnostic  evidence. 

Remember  that  mucus  in  the  stools  is  always  in- 
dicative of  enteritis,  and  never  occurs  from  ulcer  or 
cancer  alone ;  but  the  presence  of  blood  always  signi- 
fies a  complication,  such  as  piles,  ulcer,  or  cancer. 
Undigested  portions  of  meats,  fats,  and  starch  may 
be  abundant. 

"Sago-pearls"  are  swollen,  glassy  particles  of 
mucus,  and  may  be  seen  in  the  stool.  Yellow  mucus 
granules  are  soft  particles  of  mucus  stained  by  bile 
pigment,  and  originate  in  the  small  bowel.  Colicky 
pains  over  lower  portion  of  abdomen,  tenesmus,  and 
gaseous  distention  are  often  present.  Where  colitis 
exists,  tenderness  over  the  course  of  the  colon  may 
be  elicited  by  jDalpation.  There  is  pallor  and  loss 
of  flesh. 

Treatment. 

The  diet  is  of  great  importance.  It  must  be 
nourishing,  so  that  the  patient's  strength  is  built 
up  and  yet  avoid  irritating  the  bowel.  Meats  suit- 
able are  white  meat  and  fish,  scraped  beef,  calves* 
brains,  chopped  meats.  Broths,  eggs — raw,  soft 
boiled,  or  scrambled — may  be  added.  Farinaceous 
foods.  Broths  are  liable  to  irritate,  and,  when 
given,  the  vegetables  and  meat  should  be  strained 


CHRONIC    ENTERITIS.  31 

out.  Rice,  sago,  and  arrow-root  are  good.  Milk  is 
excellent;  one  to  two  quarts  daily;  add  lime  water  if 
it  causes  any  trouble.  Fats — only  form  is  butter. 
Fresh  fruit  should  be  entirely  forbidden. 

Time.    Meals  should  be  given  five  times  a  day. 

The  stools  should  be  watched  for  particles  of 
undigested  food  or  milk  curds. 

Colonic  irrigation  is  best  if  the  large  bowel  is  in- 
volved. May  use  warm  water,  saline  solution,  or 
olive  oil.  Castor  oil  or  calomel  is  best  laxative,  and 
should  be  given  in  one  dose  to  prevent  irritation  of 
mucosa.  Astringents  may  be  needed  to  control  the 
diarrhea ;  these  may  be  added  to  irrigation  solution, 
using  tannin  1  dram  to  the  quart,  or  boracic  acid 
5:1000,  or  silver  nitrate  1:2000. 

Medication.  Tannigen  and  tannalbin  are  excel- 
lent astringents.  They  are  tasteless,  and  are  not 
affected  by  gastric  juice. 

B     Tannalbini    gr.  xv 

Fiat  capsula  No.  I.  Dentur  tales  capsulse  No.  XXX. 
Sig. :  4  to  6  capsules  daily. 

Or: 

IJ     Tannigeni  gr.  vi j 

Fiat  capsula  No.  I.  Dentur  tales  capsulae  No.  XX. 
Sig.:  Capsule  every  two  hours. 

Alum  gr.  iss-gr.  iv  may  be  given  every  two  hours. 
Lead  acetate  gr.  ss-gr.  iss  may  be  administered. 
Silver  nitrate  internally  is  not  efficacious,  as  hydro- 
chloric acid  in  the  stomach  converts  it  into  the  chlo- 
rid;  when  used,  it  should  be  given  in  capsules  hard- 
ened with  formalin,  so  that  the  gastric  juice  will 


32  DISEASES    OF   THE    INTESTINES. 

have  no  effect.     Bismuth  is  excellent;  use  either 
subnitrate  or  salicylate  in  large  doses. 

IJ     Bismuthi  subnitratis   gr.  xx-gr.  xxv 

Extract!   opii    gr.  %-gr.  % 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  doses  No.  XXX. 
Sig. :  Powder  every  two  or  three  hours. 

Or: 

B     Bismuthi  subnitratis  gr.  xxx 

Bismuthi  subgallatis   gr.  x 

Misce  et  fiat  charta  No.  I.     Dentur  tales  chartae  No.  X. 
Sig.:  Powder  every  two  or  three  hours. 

Or: 

B     Plumbi   acetatis    9  j 

Extracti  opii   3  ss 

Resorcinolis    (Merck)    3  iss 

Misce  et  fiant  capsulae  No.  X. 

Sig.:   Capsule  every  three  hours. 

Or: 

U     Salolis     3  j 

Sodii  bicarbonatis, 

Sodii  benzoatis, 

Bismuthi  salicylatis   aa  3  iss 

Misce  et  fiant  pulveres  No.  XX. 
Sig.:  Powder  every  four  hours. 

Obstruction  of  the  Bowel. 

Remember  that  the  symptom  complex  will  vary 
according  to  the  degree  of  obstruction.  There  may 
be  slight  difficulty  in  the  discharge  of  feces,  or  fecal 
retention  may  occur,  and  onset  may  be  sudden  or 
gradual. 

Accumulation  of  feces  and  gases  occurs  above 
constricted  area.    Distention  of  abdomen.    Peristal- 


OBSTRUCTION   OF   BOWEL.  33 

tic  waves  can  be  seen  above  obstruction.  In  complete 
obstruction  there  are  great  distention,  collapse, 
feeble  pulse,  coldness,  and  cyanosis  of  tbe  extremi- 
ties. Vomiting,  at  first  greenish,  later  resembles 
feces  and  has  a  fecal  odor. 

Intussusception. 

Remember  that  it  most  often  occurs  at  iliocecal 
junction,  and  usually  found  in  infancy. 

1.  Sudden  onset  of  pain — severe,  continuous,  or 
paroxysmal;  referred  to  umbilicus. 

2.  Vomiting  occurs  early.  More  constant  in  chil- 
dren.   Rarely  have  fecal  vomiting  in  children. 

3.  Stools  are  characteristic,  containing  blood  and 
mucus.    Tenesmus  is  severe. 

4.  Tumor  is  egg  or  sausage-shaped,  movable,  and 
firm.  It  changes  its  position  as  the  intussusception 
progresses.  Treves  says,  "It  nearly  always  can  be 
felt  during  pain. ' '  Clubbe  says, ' '  Very  sudden  onset 
in  previously  healthy  baby  is  a  peculiarity  of  intus- 
susception. The  child  screams,  turns  pale,  vomits, 
which  ceases  but  to  recur  again. ' ' 

5.  Pulse  and  temperature  remain  normal. 
Issue.    May  terminate  in  one  of  three  ways: 

1.  Union  at  the  point  of  invagination,  with 
sloughing  of  the  invaginated  portion  of  the  gut,  and 
recovery.     (Rare.) 

2.  Peritonitis. 

3.  Ulceration  and  perforation. 


34  diseases  of  the  intestines. 

Treatment. 

Never  administer  cathartics  and  purgatives,  even 
in  fecal  impaction.  Enemata  of  water  or  saline  solu- 
tion with  rectal  tube,  with  hips  of  the  patient  ele- 
vated, is  best.  If  an  intussusception  is  seen  early, 
the  distention  of  the  bowel  with  either  air  or  water 
may  reduce  it;  but  if  the  invaginated  portion  be- 
comes edematous,  it  will  be  of  no  avail. 

Remember  that  it  is  a  safe  rule  to  operate  in  in- 
testinal obstruction  of  any  cause  other  than  fecal 
impaction,  and  do  it  early  before  peritonitis  sets  in. 

Remember  that  obstruction  of  the  bowel  due  to 
fecal  accumulation  is  positively  the  only  form  that 
does  not  belong  to  the  surgeon. 

Chronic  Constipation. 

Remember  that  persistent  constipation,  continu- 
ing for  weeks,  is  incompatible  with  good  health. 

Remember  that  constipation  is  a  relative  term. 
Autointoxication  is  supposed  to  be  the  cause  of  a 
great  many  ills  due  to  the  resorption  of  noxious  mat- 
ter from  retained  feces. 

Remember  that  the  fecal  mass  may  become  chan- 
neled and  diarrhea  occur.  An  habitually  consti- 
pated woman,  seized  with  diarrhea,  nausea,  and 
vomiting,  should  cause  a  thorough  examination  of 
the  large  bowel. 

Remember  that  dysmenorrhea  and  sacral  neural- 
gia may  be  caused  by  impacted  feces.  Piles,  colonic 
ulceration,  occlusion  of  the  bowel,  and  perforation 


CHRONIC    CONSTIPATION.  35 

may  be  caused  by  persistent  retention.  As  a  rule, 
raental  depression,  lassitude,  headache,  coated 
tongue,  and  anorexia  are  the  more  common  symp- 
toms.   Attack  of  colic  may  occur. 

Treatment  .  ' 

Diet  is  very  important.  Coarse  foods,  as  whole 
wheat,  rye,  or  cornmeal  bread.  Fruits,  except  ba- 
nanas. Vegetables,  as  cabbage,  turnips,  tomatoes, 
spinach,  onions,  celery.  Sweets,  if  they  do  not  cause 
indigestion,  are  laxative.  Fats,  as  butter  and  olive 
oil.  Water  freely  during  the  day;  a  glass  of  water 
at  night  or  morning  acts  beneficially.  Punctuality 
at  the  stools  must  be  urged ;  best  time  is  after  break- 
fast. 

Massage  will  relieve  if  continued  for  a  long  period 
of  time.  The  hand  should  be  placed  over  the  cecum 
and  follow  the  course  of  the  colon.  This  is  contra- 
indicated  in  spastic  constipation.  Exercise  of  the 
body  in  tennis,  rowing,  lifting  the  legs  while  lying 
on  the  back,  walking. 

Enemata  will  stimulate  peristalsis  and  lessen  con- 
gestion. Overdistention  produces  colonic  dilata- 
tion; hence,  in  time,  they  lose  their  beneficial  effects. 

Drugs.    Aloes  and  strychnin  are  indicated. 

I^     Extract!  aloes   gr.  ss 

Extract!  rhe! gr.  i j-gr.  v 

Extract!  nuc!s  vomicae gr.  1,4 

E,es!n8e  podophyll!    gr.  i,{o 

Extract!   belladonnse    gr.  ^ 

Extract!  taraxac!  gr.  j 

M!sce  et  fiat  pilula  No.  I. 

Sig. :  P!ll  night  and  morning.     Not  to  be    given    in   preg- 
nancy. 


36  DISEASES   OF   THE    INTESTINES. 

Or: 

IJ     Extract!  belladonnse g^^•^2 

Extract!  nucis  vomicae gr.  % 

Extract!  colocyntliidis   gr.  ij 

Misce  et  fiat  pilula  No.  I. 

Sig. :   Pill  three  times  daily. 

In  atony  of  the  bowel  use: 

IJ     Extract!  rhamn!  purshianse 3  j 

Extract!  nucis  vomicae gr.  viij 

Extract!  physostigmatis    gr.  ij 

Extract!  hyoscyaminse  gr-  v 

Misce  et  fiant  pilulae  No.  XXX. 

Sig.:  Pill  night  and  morning. 

If  anemic,  add  iron  or  use: 

IJ     Ferr!  sulphatis   gr-  x 

Extract!  aloes  aquosi  gr.  v 

Extract!  rhamni  purshianae   gr.  xx 

Extract!  belladonnse, 

Extract!  nucis  vomicae   aa  gr.  iij 

Misce  et  fiant  pilulae  No.  X. 
Sig.:  Pill  after  meals. 

In  old  people  use  the  following: 

IJ     Aloini    gr.  vj 

Podophyll!    gr.  ij 

Misce  et  fiant  pilulae  No.  XII. 
Sig.:  Pill  night  and  morning. 

Phenolphthalein  is  good  and  causes  no  griping. 
It  is  the  principal  ingredient  in  recent  proprietaries. 
It  is  not  harmless,  as  collapse,  with  vomiting  and 
diarrhea,  have  occurred  with  purgen. 

IJ     Fluidextract!  rhamni  purshianae  aro- 
matic!    S  iv 

Sig.:  Teaspoonful  night  and  morning.  The  morning  dose 
taken  with  a  glass  of  hot  water  half  an  hour  before  break- 
fast. 


APPENDICITIS.  37 

Gradually  withdraw  drug  as  habit  of  daily  evacu- 
ation is  established. 

Appendicitis. 

Remember  that  the  various  forms  described  are 
only  various  stages  in  the  progressive  changes  of 
one  pathological  condition,  and  that  an  unchecked 
inflammation  of  the  appendix  will  terminate  in  gan- 
grene and  death.  Of  all  the  inflammatory  condi- 
tions in  the  abdomen  occurring  in  persons  under 
thirty,  appendicitis  is  by  far  the  most  common. 

Remember  that  sudden  pain  in  the  right  iliac 
fossa,  fever,  rigidity  of  right  rectus  muscle,  and 
localized  tenderness  is  appendicitis  almost  without 
a  single  exception. 

Remember  that  fecal  vomiting,  a  very  common 
symptom  of  obstruction,  is  never  seen  in  appendi- 
citis. 

Remember   that   marked    tenesmus    and    bloody 
stools  in  children  are  the  signs  of  intussusception  ' 
and  not  appendicitis. 

Remember  that  the  thermometer  is  one  of  the 
most  trustworthy  guides  in  diagnosing  appendicitis, 
and  Murphy  says  he  would  refuse  operation  if  no 
fever  was  present  during  the  first  thirty-six  hours 
of  the  disease. 

Remember  that  the  subsidence  of  excruciating 
pain  is  an  ominous  sign  of  gangrene,  and  perfora- 
tion is  not  far  distant. 

Remember  to  exclude  the  onset  of  pneumonia  in 


38  DISEASES    OF    THE    INTESTINES. 

cases  of  sudden  colicky  pain  in  abdomen  of  children 
by  auscultating  the  chest. 

Remember  that  typhoid  bacilli  may  cause  appen- 
dicitis and  many  cases  of  perforation  occur  through 
typhoid  ulcer. 

Never  mask  your  symptoms  with  morphin;  it  is 
positively  suicidal  for  both  doctor  and  patient.  If 
the  patient  complains  of  pain  in  emptying  the  blad- 
der or  rectum,  always  examine  per  rectum  for  recto- 
vesical or  rectouterine  tenderness,  or  an  inflamma- 
tory swelling. 

Tenderness  at  the  right  side  of  the  rectum  in  rec- 
tal examination  is  nearly  always  present,  although 
there  may  be  none  at  McBurney's  point. 

Masked  Appendicitis. 

In  this  form  there  is  no  history  of  an  acute  attack, 
and  the  usual  clinical  picture  of  appendicitis  is 
absent. 

1.  Dyspepsia,  with  belching,  pain  at  irregular 
intervals  following  meals,  persisting  for  a  time,  fol- 
lowed by  a  period  of  complete  disappearance  of  all 
symptoms  regardless  of  diet. 

2.  Diarrhea,  especially  early  morning,  with  two 
or  three  loose  movements,  with  freedom  from  it  for 
balance  of  the  day.  Evacuations  may  be  preceded 
by  colicky  pains,  which  the  evacuations  relieve. 
At  times  there  is  a  peculiar  periodicity  of  diarrhea, 
occurring  at  a  certain  morning  hour.  There  are 
periods    of    freedom    from    diarrhea,    just    as    the 


APPENDICITIS.  39 

gastric  symptoms.  The  stools  may  be  normal  at 
first,  but  later  become  slimy  and  contain  mucus. 
Persistent  constipation,  with  extreme  neurosis,  may 
occur. 

3.  Pain  is  paroxysmal,  with  all  degrees  of  sever- 
ity. Occurs  suddenly,  often  in  the  epigastric  region, 
accompanied  by  nausea  and  vomiting, 

4.  Palpation  over  the  appendicular  area  will  usu- 
ally reveal  tenderness  and  often  causes  nausea.  The 
swollen  appendix  can  be  palpated  through  a  re- 
laxed abdominal  wall  if  not  too  thick. 

Remember  that  disease  of  the  gallbladder, 
stomach,  and  pelvis  must  be  excluded  before  mak- 
ing a  positive  diagnosis.  Have  the  patient  lie  on  the 
back  and  limbs  straight.  With  the  tips  of  the  fingers 
over  the  cecum,  make  deep  pressure.  Now  tell  the 
patient  to  make  the  muscles  of  the  right  limb  rigid 
and  stiff  at  the  knee,  and  raise  the  foot  by  using 
hip  joint  and  lifting  as  against  a  weight.  If  the 
appendix  is  at  all  tender,  he  will  complain  of  pain. 

Treatment. 

Remember  that  the  treatment  of  appendicitis  is 
always  surgical,  regardless  of  type,  time,  or  tender- 
ness. The  danger  of  perforation  and  general  peri- 
tonitis occurring  at  any  hour  should  always  be  kept 
in  mind,  and  warn  us  against  useless  medication. 

If  an  operation  is  absolutely  prohibited,  then 
Oschner's  method  gives  best  results.  Give  abso- 
lutely nothing  by  mouth;  use  nutrient  rectal  ene- 


40  DISEASES    OF    THE    INTESTINES. 

mata.  If  vomiting  is  present,  wash  out  the  stomach. 
Apply  an  ice  bag  over  the  cecum.  Use  continuous 
seepage  (page  29)  of  normal  saline.  If  pain  is 
intense,  use  enough  morphin  to  make  it  bearable,  but 
never  entirely  relieve  it. 

Mucous  Colitis. 

Remember  that  this  is  a  neurosis,  and  is  found 
in  hysterical  or  hypochondriacal  patients.  They  are 
dyspeptics,  and  have  carried  self-dieting  to  such  ex- 
tremes that  they  become  thin  and  anemic. 

The  diagnostic  sign  is  mucus — either  as  strips, 
shreds,  or  casts — passed  at  stool.  Other  times  it  is 
a  slimy,  gelatinous  mass,  resembling  frog-spawn. 
Usually  occurs  at  intervals  and  follows  prolonged 
constipation.  Colicky  pain,  usually  agonizing,  with 
tenesmus,  is  present.  These  mucous  segments  are 
often  mistaken  for  segments  of  tapeworm. 

There  is  tenderness  over  the  colon,  and  often  a 
spot  of  great  tenderness  between  the  navel  and  left 
costal  arch.  Abdomen  is  rarely  distended.  Mucous 
casts  may  be  found  in  the  urine.  Urticaria  and  boils 
are  frequently  associated  with  this  condition. 

Treatment. 

Plenty  of  outdoor  exercise  should  be  given.  Diet 
must  be  liberal,  and  consist  of  the  ordinary  foods; 
should  be  well  cooked  and  served  at  regular  time. 
Foods  leaving  considerable  residue  are  good  to  over- 
come constipation. 


MUCOUS   COLITIS — VISCEROPTOSIS.  41 

Constipation  is  best  prevented  by  castor  oil.  Give 
in  morning  on  empty  stomach  and  enough  to  open 
the  bowel.  Calomel  or  magnesium  sulphate  may  be 
used,  but  are  not  so  good.  Pain  can  usually  be  re- 
lieved by  hot  applications  to  the  abdomen,  but  at 
times  it  is  so  severe  as  to  require  hypodermic  of 
morphin  combined  with  atropin. 

Irrigate  the  colon  with  normal  saline  solution. 
In  severe  neurosis  use  the  Weir-Mitchell  method  of 
feeding.    Quiet  the  nervous  condition  with  bromids. 

At  night  inject  as  high  as  possible  half  to  a  pint 
of  warm  olive  or  cottonseed  oil.  Have  patient  re- 
tain the  oil  all  night  if  possible.  This  usually  causes 
a  copious  evacuation  in  the  morning.  Continue  this 
every  night  for  two  or  three  weeks,  then  every  other 
night  for  same  period,  then  three  times  a  week. 

Arsenic  and  the  glycerophosphates  will  often  give 
excellent  results. 

Visceroptosis. 

To  determine  the  degree  of  displacement  of  the 
abdominal  organs,  accurately  and  easily  applied  sur- 
face markings  of  the  normal  position  of  the  organs 
are  essential.    The  following  lines  will  be  of  aid : 

The  sternoensiform  line  is  drawn  across  the  body 
at  the  junction  of  sternum  and  ensiform.  It  marks 
the  height  of  the  abdominal  viscera.  In  the  right 
nipple  line,  with  patient  in  recumbent  posture, 
hepatic  dullness  begins.  Gastric  resonance  falls  half 
an  inch  below  it  on  left  side;  the  central  tendon  of 


42  DISEASES    OF    THE    INTESTINES. 

the  diaphragm  half  an  inch  below  in  median  line. 
In  addition,  this  line  indicates  the  kind  and  degree 
of  chest  deformity.  It  crosses  the  fifth  costal  on 
either  side  in  normal  chest,  but  may  cut  the  fifth 
space  in  emphysema  because  the  ribs  and  cartilages 
are  abnormally  horizontal;  or  it  may  cut  the  fourth 
space  or  fourth  rib  if  the  ribs  are  abnormally  de- 
pressed, as  they  so  often  are  in  visceroptosis. 

The  midepigastric  point  is  midway  between  the 
umbilicus  and  the  sternoensiform  junction. 

The  transpyloric  line  passes  through  this  point. 
It  cuts  the  costal  margin  near  the  outer  border  of 
the  recti  and  crosses  the  ninth  costal  cartilage. 

The  pylorus  is  situated  on  this  line,  halfway  be- 
tween the  midepigastric  point  and  the  costal  mar- 
gin. In  ptosis  it  is  displaced  downward  and  toward 
the  median  line. 

The  lesser  gastric  curvature  is  about  three-fourths 
of  an  inch  above  and  the  greater  curvature  one  and 
one-half  inches  below  the  midepigastric  point;  this 
point  marks  the  lower  hepatic  margin  as  it  crosses 
the  body,  while  behind  it  the  pancreas  crosses  the 
spinal  column. 

The  umbilical  line  is  drawn  through  the  umbilicus 
and  touches  the  iliac  crests. 

The  transverse  colon  lies  just  above  it,  while  the 
lower  poles  of  the  kidneys  do  not  reach  it.  In  ptosis 
both  colon  and  kidneys  fall  below  this  line. 

Symptoms.  A  high  degree  of  ptosis  may  cause  no 
symptoms. 


VISCEROPTOSIS.  43 

1.  Circulatory  disturbances  are  manifested  by  diz- 
ziness, fainting,  flushing  of  the  head,  and  palpi- 
tation in  the  upright  position,  but  relief  is  obtained 
on  lying  down. 

2.  Grastric  symptoms  are  anorexia,  nausea,  vom- 
iting, and  eructations. 

3.  Nervous  group  includes  pain  or  dragging  sen- 
sation in  back  or  loins,  neuralgic  pains  in  the  head, 
sleeplessness,  despondency,  and  reflex  cough. 

4.  Intestinal — constipation  is  the  rule,  but  diar- 
rhea is  present  if  mucous  colitis  exists. 

Eespiration  is  costal,  superficial,  and  apex  beat 
of  heart  may  be  seen  in  sixth  space,  and  visible  tug 
on  strictures  at  root  of  neck.  Epigastric  area  sinks 
in,  and  hypogastric  region  protrudes  in  erect  pos- 
ture. The  skin  is  of  grayish  hue,  and  cold  and 
clammy.  Hands  and  feet  readily  become  cold.  The 
abdominal  organs  are  displaced  downward.  The 
pancreas  is  palpable  as  a  cord  crossing  spinal 
column. 

Treatment. 

Diet  should  be  liberal,  with  a  view  of  putting  on 
fat,  thus  furnishing  additional  support  to  the  viscera. 
I'orced  feeding  on  the  Weir-Mitchell  plan  is  excel- 
lent, because  the  nervous  system  improves  in  addi- 
tion to  the  benefit  derived  from  the  fat. 

Mechanical  support  for  the  viscera  may  be  ob- 
tained by  using  abdominal  bandage  or  adhesive 
strips.  If  the  binder  be  used,  it  should  fit  snugly, 
and  have  straps  to  prevent  "riding  the  hips."    If 


44  DISEASES    OF   THE   INTESTINES. 

adhesive,  use  six-inch  zinc  oxid,  and  cut  them  long 
enough  to  extend  three-fourths  around  the  body. 
Apply  in  recumbent  posture,  beginning  in  the  hypo- 
gastric region. 

Drugs  are  indicated  when  tonics  are  needed. 
Strychnin  may  then  be  used  to  good  advantage. 
Operation  for  replacing  organs  and  suturing  them 
is  indicated  in  a  few  cases  with  neurasthenia,  yet 
not  all  neurasthenics  should  be  operated  upon. 

Caution.  When  visceroptosis  is  discovered  in  a 
patient,  it  is  well  not  to  tell  him,  as  it  often  forms  a 
basis  for  many  imaginary  disorders  in  the  neuras- 
thenic or  hysterical. 


CHAPTER  III. 

DISEASES  OF  THE  LIVER. 

Icterus  (Jaundice). 

Remember  that  icterus,  or  jaundice,  is  a  symptom, 
and  may  be  found  in  a  variety  of  conditions.  It  is 
due  to  alteration  of  bile  or  occlusion  of  ducts. 

Examine  the  urine  before  diagnosing  jaundice,  al- 
though the  tissues  be  discolored.  When  the  urine 
contains  bile  pigments,  the  froth  formed  by  shaking 
it  is  colored  yellow.  Nitric  acid  will  give  the  play 
of  colors,  best  observed  on  a  white  porcelain  dish. 
Albumin  will  usually  be  found  in  the  urine. 

Remember  that  the  pulse  and  respirations  are 
greatly  reduced  in  frequency,  especially  the  respira- 
tory rate. 

Remember  that  cholemic  intoxication  may  occur, 
manifested  by  delirium,  coma,  convulsions,  and 
death. 

Remember  that  hemorrhages  are  frequent,  and  no 
operation  should  be  attempted  unless  absolutely  nec- 
essary. 

Intense  pruritus  and  sweating,  often  localized  to 
the  palms  and  abdomen,  occur  in  chronic  icterus. 

Grayish-colored  stools,  with  putrid  odor,  are  due 
to  the  absence  of  bile  in  the  intestine. 

Always  examine  the  liver  and  gallbladder  care- 
fully in  all  cases  of  jaundice. 


46  diseases  of  the  liver. 

Treatment. 

Diet.  Avoid  fats,  alcohol,  tea,  coffee,  and  meats. 
An  exclusive  milk  diet  is  best.  Calomel  in  broken 
doses  (gr.  ^  hourly  until  gr.  iij  are  taken),  followed 
in  four  hours  by  saline.  The  bowels  may  be  regu- 
lated by  copious  enemata;  these  are  supposed  to 
stimulate  contractions  of  the  gallbladder.  Or  saline 
aperient  waters  may  be  given;  best  given  on  arising 
before  food  is  taken. 

Where  gastrointestinal  catarrh  exists,  the  follow- 
ing may  be  used : 

B     Acidi  hydrochlorici  diluti    3  j 

Tincturae  nucis  vomicae 3  iv 

Tincturae  gentianae  compositse  q.  s.  ad  3  iv 
Misce. 
Sig. :  Teaspoonful  after  meals. 

Or: 

IJ     Creosoti    TTl,  iv 

Bismuthi   subcarbonatis    3  j 

Aquae  calcis q.  s.  ad  S  j 

Misce. 

Sig.:  Teaspoonful  every  half  hour. 

Catarrh  of  bile  duct  use: 

IJ     Sodii  salicylatis    3  iv 

Ammonii  muriatici    §  j 

Aquae  menthae  piperitae    .  .  .  .  q.  s.  ad  ^  vj 
Misce. 
Sig. :    Dessertspoonful  after  meals. 


Or: 


IJ     Fel  bovis    gr.  xxx 

Salolis     3  ij 

Misce  et  fiant  capsulae  No.  XII. 

Sig. :  Capsule  three  hours  after  meals. 


ICTEEUS POETAL    CLRRHOSIS.  47 

Or: 

IJ     Extract!  aloes   3  ss 

Sodii  biearbonatis    3  j 

Extract!  taraxaci    q.  s 

Misce  et  fiant  p!lulge  Xo.  LX. 

S!g. :  2  p!Il3  mght  and  mormng.     f  Catarrhal.) 

Or: 

E     Suce!  taraxaci   B  !j 

Sod!!  bicarbonatis    3  vj 

Tincturse  rhei    3  vj 

Infus!  gent!an£E    q.  s.  ad  §  x!j 

Misce  et  fiat  misturse. 

Sig. :   Tablespoonful  three  times  daily.    (  Catarrhal.  )- 

Urotropin  gr.  v-gr.  vj  three  times  a  day  should  be 
administered  for  its  po^ver  over  any  inflammatory 
condition  in  the  gallbladder.  Sodium  salicylate  in 
5-grain  doses  every  four  hours  also  has  a  beneficial 
influence  on  the  consistency  of  the  bile.  For  the 
itching  use  Trarm  baths,  or  pilocarpin,  given  hypo- 
dermatically  gr.  Yio-gT.  Yq,  has  been  highly  recom- 
mended. The  chilling  of  the  skin  must  be  prevented 
by  warm  clothing.  In  chronic  cases  dilute  nitro- 
hydrochloric  acid  in  20-minim  doses  in  half  an  ounce 
of  the  infusion  of  calumba  an  hour  before  meals  is 
often  used.  Silver  nitrate  gr.  %  three  times  daily 
over  long  period  is  highly  spoken  of,  but  should  be 
used  cautiously. 

Portal    Cirrhosis    (Laennec's    Cirrhosis,    Alcoholic 
Cirrhosis). 

Remember  that  it  usually  occurs  past  forty  years 
of  age,  and  frequently  vith  an  alcoholic  history.  The 


48  DISEASES    OF    THE    LIVER. 

liver  is  shrunken;  hence  dullness  on  percussion  is 
diminished,  especially  over  the  left  lobe.  In  ad- 
vanced cases  nodules  may  be  felt  along  the  borders 
of  the  liver. 

Remember  that  jaundice  is  rare  in  this  form  of 
cirrhosis,  but  obstruction  to  the  portal  vein  radicles 
causes  congestion  of  gastrointestinal  mucosa. 
Hemorrhage  is  frequent,  either  from  esophageal 
veins,  the  stomach,  the  intestines,  or  hemorrhoids. 
Ascites  occurs,  and  the  amount  of  fluid  in  the  abdo- 
men may  be  so  large  as  to  endanger  life  unless  re- 
lieved. Dropsy  of  lower  extremities  (anasarca)  oc- 
curs after  the  ascites,  and  is  caused  by  the  pressure 
of  the  ascitic  fluid  upon  the  large  veins. 

Remember  that  in  the  nutmeg  liver,  due  to  car- 
diac lesion,  the  anasarca  precedes  the  ascites  and  is 
due  to  failing  cardiac  force. 

Remember  that  in  portal  cirrhosis  the  abdominal 
veins  are  distended,  due  to  an  attempt  to  establish 
collateral  circulation. 

Remember  that  nutrition  suffers,  urea  excretion 
is  less,  and  albumin  is  usually  found  in  the  urine. 

Always  make  a  pelvic  examination  in  women,  so 
as  to  exclude  an  ovarian  cyst. 

Treatment. 

Alcohol  in  any  form  must  be  absolutely  prohibited. 
Do  not  prescribe  tinctures  in  the  treatment.  All 
spices  and  irritants  must  be  excluded. 

The  diet  must  be  plain  and  simple,  easy  to  digest, 


POETAI.    CIRRHOSIS.  49 

and  nutritious.  At  tlie  beginning  of  treatment  an 
exclusive  milk  diet  is  best.  Vegetables  may  be 
added;  always  use  those  containing  least  amount  of 
starcb.  Later  white  meats  may  be  allowed.  Com- 
plete rest  and  plenty  of  fresh  air  is  necessary. 
Bowels  should  be  kept  open  by  salines  or  calomel. 
Avoid  drastic  purgatives;  rhubarb,  senna,  cascara. 
or  cream  of  tartar  may  be  used. 

If  hematemesis  occurs,  rest  in  bed  and  treatment 
outlined  under  that  head  should  be  followed. 

Remember  that  diarrhea  in  these  cases  is  often 
beneficial,  and  do  not  be  too  anxious  about  checking 
it,  for  ascites  can  be  relieved  by  drugs  only  through 
the  kidneys  or  bowels. 

To  increase  urination,  the  following  is  good: 

B     Hydrargyri  chloridi  mitis, 

Pulveris  digitalis, 

Pulveris    scillse    aa  gr.  vj 

Misce  et  fiant  pilulse  No.  VI. 
Sig. :  Pill  three  times  daily. 

Or: 

R     Potassii  citratis, 

Potassii  acetatis    aa  3  iiss 

Spiritus  setheris  nitrosi    3  iv 

Liquoris  ammonii  acetatis   §  i j 

Tineturse  digitalis    TT[,  Ixxx 

Syrupi  acidi  citriei   q.  s.  ad  ^  iv 

Misce. 

Sig.:  Dessertspoonful  four  times  daily. 

To  purge,  use: 

IJ     Elaterini     gr.  j 

Pulveris  glycyrrhizse    q.  s. 

Misce  et  fiant  pilulse  No.  VIII. 

Sig. :  1  pill  every  four  hours  until  free  catharsis. 


50  DISEASES    OF    THE    LIVER. 

Apocynmn  cannabinum  is  an  excellent  drug. 
Specific  tincture  (Lloyd)  is  generally  used  in  doses 
of  2  to  3  minims  every  three  hours;  often  called  the 
vegetable  trochar.  The  iodids  and  ammonium  chlo- 
rid  are  thought  by  some  to  be  beneficial. 

I^     Ammonii   iodidi    3  j 

Tincturae    eardamomi    compositse    . .  3  iv 

Aquae  menthse  piperitse    .  .  .  .  q.  s.  ad  §  i j 
Misee. 
Sig. :   Teaspoonful  before  meals. 

Or: 

IJ     Ilydrargyri  perchloridi    gr.  j 

Ammonii  chloridi   3  ij 

Syrupi  tolutani o  j 

Aquae    q.  s.  ad  c|  ii  j 

Misce. 

Sig.:  Teaspoonful  three  times  daily. 

Ascites  should  be  relieved  by  paracentesis.  This 
is  by  far  the  safest  course,  and,  with  very  ordinary 
care  and  cleanliness,  is  practically  harmless.  Don't 
wait  for  a  large  accumulation  of  fluid,  so  that  res- 
piration, digestion,  and  cardiac  contractions  are  in- 
terfered with.  Tonics  should  be  used,  and  of  these 
none  are  better  than  the  following: 

IJ     Elixiris  ferri,  quininae  et  strychninae  5  ij 
Sig.:  Dessertspoonful  after  meals. 

It  should  be  remembered  that  each  dose  contains 
%o  grain  of  strychnin. 

Surgery  offers  no  better  result  than  medicine  in 
these  cases.  Collateral  circulation  will  relieve  por- 
tal congestion,  but  throws  products  directly  into  the 
systemic  circulation  that  should  first  be  modified 
by  specific  action  of  liver. 


BILIARY    CIRRHOSIS.  51 

Biliary  Cirrhosis. 

Remember  that  in  this  form  of  cirrhosis  there  is 
no  ascites,  but  chronic  jaundice  and  an  enlarged 
spleen.  It  occurs  in  early  adult  life.  Heredity  is 
a  factor,  and  many  cases  are  on  record  of  families 
developing  this  condition.  In  many  of  the  specific 
fevers,  as  scarlatina  and  typhoid,  it  develops. 
Pyogenic  cocci  have  been  found  in  many  cases; 
hence  it  is  probably  of  toxic  origin. 

Remember  that  this  occurs  between  the  twentieth 
and  thirty-fifth  years;  there  is  no  alcoholic  history. 
Chronic  icterus  without  ascites,  with  bile  pigments 
in  the  urine.  The  stools  are  of  normal  color,  and  the 
liver  and  spleen  are  enlarged.  These  are  the  char- 
acteristics of  Hanot's  cirrhosis. 

Remember  that  the  onset  is  announced  by  fever, 
anorexia,  pain  and  dragging  in  hepatic  region,  with 
swelling  of  liver  and  spleen.  The  fever  subsides, 
the  patient  feels  well,  but  the  liver  and  spleen  re- 
main large.  These  acute  exacerbations  occur  peri- 
odically.   Hemorrhage  is  very  rare. 

Remember  that  it  is  rare  to  find  jaundice  in  por- 
tal cirrhosis,  while  ascites  is  common. 

The  presence  of  gallstone  causes  attack  of  colic, 
in  which  the  pain  is  severe  and  agonizing,  but  the 
spleen  is  not  enlarged,  the  jaundice  is  deeper,  and 
the  stools  are  clay-colored. 

Malignant  disease  of  the  liver  runs  a  much  shorter 
course;  there  is  great  wasting  and  frequent  occur- 
rence of  complete  obstruction,  with  jaundice.     The 


52  DISEASES    OF  THE   LIVER. 

spleen  is  not  enlarged.    Cancer  of  the  liver  occurs 
in  advanced  life. 

Remember  that  jaundice  begins  early  and  gradu- 
ally deepens  in  contradistinction  to  portal  cirrhosis. 
The  liver  is  also  enlarged. 

Treatment. 

Patient  should  lead  a  quiet  life,  with  regulated 
exercise.  During  crisis  of  the  disease  he  should  be 
confined  to  the  bed.  Must  avoid  fatigue  and  ex- 
posure to  cold. 

Diet  must  be  simple,  nutritious,  and  easily  di- 
gested. Should  contain  no  stimulating  substances. 
During  crisis  an  exclusive  milk  diet  is  best.  Bowels 
must  be  kept  open,  and  salines  are  the  best. 
Calomel  gr.  Yw-gr.  V-i  every  three  hours  for  three 
days  or  longer  is  highly  recommended.  Salol  gr.  v- 
gr.  X  after  meals  is  indicated  in  offensive  stools.  The 
saline  mineral  waters  are  allowable.  Give  glass  be- 
fore breakfast  and  give  it  hot. 

Abscess  of  the  Liver. 

Remember  that  some  cases  can  be  diagnosed  with 
certainty,  some  probably,  and  in  some  the  diagnosis 
is  impossible. 

Make  it  a  rule,  which  should  never  be  broken, 
to  make  a  positive  diagnosis  of  liver  abscess  only 
when  a  source  for  the  formation  of  pus  has  been 
demonstrated  or  can  be  surmised  with  a  great  de- 
gree of  probability. 


ABSCESS    OF   LIVER.  53 

Always  pay  special  attention  to  inflammations  in 
the  region  of  the  portal  vein — gastric  ulcer,  appen- 
dicitis, dysentery,  purulent  hemorrhoids. 

Remember  that  it  may  follow  wounds,  especially 
of  bones  of  the  head  or  of  body;  gallstones,  pulmon- 
ary gangrene,  endocarditis. 

Remember  that  the  presence  of  fever  narrows  the 
diagnosis  to  hepatic  abscess  and  acute  yellow  atro- 
phy.   Fever  is  very  rare  in  carcinoma. 

Remember  that  the  liver  is  usually  enlarged,  and 
it  is  most  marked  in  the  right  lobe;  in  contradistinc- 
tion to  all  other  enlargements,  it  is  upward.  It  is 
most. pronounced  in  midaxillary  line  on  percussion, 
and  is  usually  normal  at  the  vertebral  column  and 
at  the  midsternal  and  parasternal  lines.  While  there 
is  some  icterus  present,  marked  jaundice  is  rare. 
There  is  usually  pain,  but  the  intensity  varies,  and 
the  liver  is  painful  on  palpation,  especially  so  over 
<;ertain  areas,  probably  corresponding  to  the  abscess 
area  or  to  circumscribed  peritonitis  caused  by  the 
abscess. 

Remember  that  the  spleen  is  never  enlarged,  ex- 
cept where  the  abscess  is  caused  by  pylephlebitis  or 
pyemia. 

Remember  that  some  cases  closely  resemble  ma- 
laria. The  fever  intermits,  and  the  patient  has  chills 
and  sweats. 

Remember  in  malaria  the  presence  of  the  Plas- 
modium in  the  blood  and  the  enlarged,  hard  spleen, 
and  that  quinin  properly  administered  invariably 
effects  a  cure. 


54  DISEASES    OF    THE    LIVER. 

In  right  side  pleuritic  exudate  the  area  of  dullness, 
spoken  of  as  characteristic  of  liver  abscess,  is  absent, 
and  a  dislocation  of  the  heart  to  the  left  is  present. 

Remember  that  the  evidence  obtained  by  punctur- 
ing the  liver  with  the  needle  is  conclusive  if  the 
needle  enters  the  abscess. 

Teeatmekt. 

Pyemic  abscess  and  suppurative  pylephlebitis  are 
invariably  fatal,  and  surgical  intervention  is  not  in- 
dicated. Abscess  following  dysentery  is  usually  sin- 
gle, and  surgery  offers  the  best  results — practically 
the  only  hope.  If  the  abscess  ruptures  into  the  pleura 
and  the  patient  cough  up  pus,  an  operation  is  not 
indicated.  There  is  no  drug  that  can  stop  or  modify 
it  in  any  way  after  the  onset.  The  best  treatment  is 
preventive. 

Acute  Yellow  Atrophy. 

Fortunately  this  fatal  ailment  is  rare. 

Remember  that  pregnancy  is  an  etiologic  factor 
in  nearly  one-half  of  the  reported  cases. 

Remember  that  it  may  occur  in  the  course  of 
biliary  cirrhosis. 

The  onset  is  deceptive,  and  is  usually  announced 
by  gastroduodenal  catarrh,  accompanied  by  slight 
icterus,  but  soon  headache,  delirium,  trembling  of 
the  muscles,  vomiting,  and  deepening  of  the  icterus 
sets  in. 

Coma  may  develop  early  and  deepens  until  death, 
or  it  may  develop  later. 


ACUTE  YELLOW  ATROPHY CANCER  OF  LIVER.      55 

Urinalysis  shows  bile  pigments,  tube  casts,  with, 
marked  reduction  of  urea  excreted,  Leucin  and 
tyrosin,  either  one  or  both,  are  usually,  but  not  al- 
ways, present.    The  stools  are  clay-colored. 

A  rapid  reduction  in  the  size  of  the  liver,  usually 
most  pronounced  in  the  left  lobe,  and,  as  a  rule,  the 
afebrile  course  following  the  initial  elevation  of  tem- 
perature, confirms  the  diagnosis. 

Treatment. 

The  disease  is  invariably  fatal.  Being  of  a  toxic 
nature,  the  channels  of  elimination  should  be  stimu- 
lated. Saline  solution  intravenously  and  free  ca- 
tharsis. Gastric  sedatives,  as  bismuth  subnitrate, 
may  be  used  to  allay  the  vomiting.  We  are  power- 
less to  check  its  progress. 

Cancer  of  the  Liver. 

Remember  that  here,  as  elsewhere  in  the  body, 
cancer,  as  a  rule,  occurs  in  those  past  midlife — at 
that  period  where  reconstructive  changes  fall  below 
the  call  of  the  tissue  cells. 

The  secondary  cancer  is  more  common  than  the 
primary,  but,  unless  the  seat  of  the  primary  cancer 
can  be  located — as  in  the  uterus,  rectum,  or  breast — 
it  is  impossible  to  make  a  differential  diagnosis. 

Remember  that  cancer  may  be  one  large  tumor, 
when  the  liver  will  be  large,  but  smooth;  or  it  may 
be  of  the  nodular  form,  when  nodules  can  be  felt 
over  lower  border  of  the  liver,  or  at  times  even  seen. 


56  DISEASES    OF   THE   LIVER. 

Always  look  for  enlarged  lymph  glands  in  the 
axilla,  inguinal  region,  or  beneath  the  skin  of  the 
abdomen  in  suspected  cases. 

Remember  that  the  liver  dullness  is  increased,  but 
that  it  is  downward  and  toward  the  umbilicus,  while 
the  upper  border  remains  normal. 

Palpation  shows  the  consistence  of  the  liver  to  be 
hard,  while  protuberances  may  be  felt.  Emaciation 
and  loss  of  strength  is  progressive. 

Remember  that  the  enlargement  of  the  liver  is 
progressive,  and  the  lower  border  may  eventually 
reach  to  the  umbilicus. 

Remember  that  the  spleen,  as  a  rule,  is  not  en- 
larged. 

Ascites  and  icterus  are  produced  by  pressure  of 
the  tumor,  and  both  may  be  extreme  or  slight.  The 
skin  is  dry,  wrinkled,  and  has  a  muddy  color.  Fever 
may  be  present,  and  be  of  intermittent  or  remittent 
type. 

Remember  that  cancer  of  the  liver  kills  in  from 
three  to  fifteen  months. 

Treatment. 

The  treatment  is  palliative.  There  is  no  thera- 
peutic measure  that  offers  much  hope.  Surgeons 
have  operated  on  a  few  early  cases  with  fair  results, 
but  this  therapeutic  measure  has  not  been  used  often 
enough  to  form  a  basis  from  which  to  draw  conclu- 
sions. 


CHAPTER  IV. 

DISEASES  OF  THE  GALLBLADDER. 

Gallstones. 

Remember  that  stones  may  remain  in  tlie  gall- 
bladder indefinitely  without  causing  any  symptoms. 
The  symptoms  are  caused  by  an  attempt  to  force  the 
stones  through  the  ducts. 

Remember  that  bacteria  produce  gallstones,  es- 
pecially the  typhoid  bacilli,  and  these  germs  have 
been  found  in  the  gallbladder  seven  years  after  an 
attack. 

Remember  that  catarrhal  inflammation  of  the  mu- 
cosa of  the  bladder  or  hepatic  duct  lays  the  founda- 
tion for  gallstones. 

Remember  that  jaundice  will  not  be  a  symptom 
if  the  stone  lodges  in  the  cystic  duct.  A  plugging 
of  the  common  duct  causes  atrophy  of  the  gallblad- 
der— just  the  opposite  of  what  would  be  expected. 

Remember  that  an  attack  of  gallstone  colic  is 
abrupt  in  onset,  and  is  announced  by  a  sudden  seiz- 
ure of  severe,  agonizing  pain  in  the  right  hypochon- 
driac region.  It  radiates  to  the  right  shoulder,  arm, 
lower  thoracic  regions,  or  it  may  be  referred  to  the 
epigastric  region.  Rigors  and  rise  of  temperature 
usually  follow.  Vomiting  and  profuse  sweating  oc- 
cur. The  vomiting  often  mitigates  the  pain,  and 
may  thus  lead  to  an  error  in  diagnosis.    The  pulse 

57 


58  DISEASES    OF    THE    GALLBLADDER. 

becomes  weak  and  rapid,  and  the  patient  may  col- 
lapse. 

Tenderness  over  the  area  of  the  gallbladder  is 
found.  Friction  sound  can  in  many  cases  be  heard; 
in  almost  all  cases  the  thrill  can  be  felt  on  palpation. 

Remember  that  the  pain  in  gastralgia  is  relieved 
by  pressure,  and  usually  terminates  suddenly  by 
eructations  and  the  voiding  of  a  large ,  quantity  of 
urine. 

The  pain  of  peptic  ulcer  is  more  constant,  and  is 
decidedly  more  directly  influenced  by  taking  of  food. 
Hematemesis  occurs  in  the  course  of  the  disease,  but 
jaundice  never. 

Treatment. 

Like  appendicitis,  the  treatment  naturally  divides 
itself  into  the  treatment  of  acute  attack  of  colic  and 
treatment  during  the  interval. 

Gallstone  Colic.  Two  things  are  necessary — first, 
to  relieve  the  spasmodic  contraction  of  the  wall  of 
the  duct,  and,  second,  to  relieve  the  pain. 

Atropin  sulphate  gr.  %o  hypodermatically,  to  be 
repeated  in  one  hour,  is  the  most  powerful  means  at 
our  command  to  relieve  spasmodic  contraction.  If 
two  doses  do  not  affect,  it  is  not  wise  to  adminis- 
ter more  atropin  because  of  danger  of  poisoning  the 
patient.  Put  the  patient  into  a  hot-water  bath  and 
keep  him  there  half  an  hour.  The  heat  relieves  pain 
and  assists  in  relaxing  the  patient. 

Morphin  is  indicated  if  no  relief  by  the  above 


GALLSTONES.  59 

treatment  is  obtained  in  one  or  two  hours.  Give 
gr.  Vi-gr.  ss  liypodermatically. 

Chloroform  inhalations  may  be  used  in  the  place 
of  morphin. 

Yeo  insists  on  giving  patient  a  tumblerful  of  very 
hot  water  to  sip  in  which  is  dissolved  1  dram  of 
sodium  salicylate  and  2  scruples  of  sodium  bicar- 
bonate, even  though  the  patient  vomits  the  first  few 
mouthfuls  swallowed. 

There  is  no  drug  that  will  dissolve  the  stones. 

Treatment  in  Interval. 

Olive  oil  is  thought  by  some  to  assist  in  passing 
stones  by  acting  as  a  solvent. 

B     Olei  olivfE B  vis 

Spiritus  vini  gallici   3  v 

Mentholis   gr.  ii j 

Vitelli  ovi    5  j 

Misce  et  fiat  emulsio. 

Sig. :  To  be  taken  within  one  hour,  one-half  a?t  a  time. 

Glycerin  is  used  by  many.  One  ounce  a  day,  with 
lemon  juice,  is  given.  Other  combinations  may  be 
used,  as: 

B     Sodii  salicylatis    3  iiss 

Aquse  menthse  piperitse   §  iv 

Misce. 

Sig.:   Dessertspoonful  three  or  four  times   a   day,   prefer- 
ably after  meals.  r 

Or: 

"^     Sodii  succinatis 9  iv 

Aquae 5j 

Syrupi  aurantii   q.  s.  ad  §  ij 

Misce. 

Sig.:   Teaspoonful  before  eating. 


60  DISEASES    OF   THE    GALLBLADDER. 

Operation  should  be  advised  in  repeated  attacks 
of  gallstone  colic,  a  distended  gallbladder  asso- 
ciated with  attacks  of  pain  or  with  fever,  and  when 
a  stone  is  permanently  lodged  in  the  common  dnct. 
It  is  best  not  to  defer  operation  too  long,  as  chronic 
icterus  of  long  duration  greatly  increases  the  dan- 
gers of  operation.  Probably  the  time  will  come 
when  the  same  rule  governing  operations  in  appen- 
dicitis will  be  followed  in  gallstone  affections. 

Suppurative  Cholangeitis. 

Remember  that  gallstones  are  the  most  frequent 
cause.  However,  typhoid,  grip,  cancer  of  the  bile 
ducts,  and  hydatid  disease  may  be  the  cause. 

Remember  that  the  infection  may  be  universal,  ex- 
tending to  practically  all  the  bile  ducts,  or  it  may  be 
limited  to  a  few  of  the  larger  ones. 

Remember  that  there  is  a  progressive  hepatic  en- 
largement, so  that  the  tumor  may  reach  the  um- 
bilicus. 

Remember  that  the  enlarged  liver  is  uniform, 
smooth,  and  tender  to  pressure. 

Remember  that  pain  is  variable,  and  may  be  ab- 
sent. It  is  usually  present  when  due  to  gallstones, 
and  it  will  then  be  paroxysmal  and  severe,  and  each 
attack  of  pain  may  be  accompanied  by  chill  and  the 
jaundice  be  intensified. 

Remember  that  icterus  is  always  present,  and  is 
persistent  and  intense. 

Remember  that  symptoms  of  an  active  infection 


SUPPURATIVE    CHOLANGEITIS.  61 

are  present,  such  as  fever,  rigors,  and  profuse  per- 
spiration.   There  is  rapid  loss  of  flesh  and  strength. 

Remember  that  the  pancreatic  ducts  are  frequent- 
ly involved  because  of  proximity,  and  there  follows 
a  pancreatic  abscess. 

Remember  that  the  gallbladder  is  usually  dis- 
tended and  palpable.  The  blood  count  shows  leu- 
cocytosis. 

Remember  that  malaria  shows  the  Plasmodium  in 
the  blood  and  the  absence  of  leucocytosis,  while  in 
suppurative  cholangeitis  the  paroxysms  of  chill, 
fever,  and  sweats  lack  the  regular  periodicity  seen 
in  malaria. 

Treatment. 

The  treatment  is  entirely  surgical.  For  the 
proper  operation,  consult  works  on  surgery.  The 
physician  should  advise  operation,  providing  the 
patient  is  in  a  condition  to  endure  it. 


CHAPTER  V. 

DISEASES  OF  THE  PANCREAS  AND 
PERITONEUM. 

Hemorrhage. 

This  is  of  great  importance  from  the  medico-legal 
point  of  view. 

Remember  that  the  onset  is  sudden,  and  the 
patient  may  be  pursuing  his  usual  occupation  when 
he  is  seized  suddenly  with  a  severe  epigastric  pain, 
which  steadily  increases  in  severity.  At  the  onset 
of  the  pain  nausea  and  vomiting  set  in.  The  vomit- 
ing is  obstinate,  consisting  at  first  of  stomach  con- 
tents and  later  is  bilious,  but  never  fecal. 

Remember  that  this  condition  is  nearly  always 
mistaken  for  intestinal  obstruction,  but  the  absence 
of  fecal  vomiting  and  the  appearance  of  a  palpable 
swelling  in  the  epigastric  region  would  exclude  ob- 
structions. 

The  patient  becomes  restless,  surface  cold  and 
clammy,  with  a  feeble,  rapid,  thready  pulse.  Tem- 
perature is  normal  or  subnormal,  and  the  patient 
loses  consciousness,  which  terminates  fatally  in 
from  twenty-four  to  forty-eight  hours. 

Treatment. 

For  loss  of  the  blood  use  saline  solution.  Relieve 
pain  and  distress  with  morphin  and  atropin.    Use 

62 


HEMORRHAGE ACUTE   PANCREATITIS.  63 

strychnin  for  heart  depression,  and  do  a  lapar- 
otomy as  soon  as  the  patient  can  be  prepared.  The 
collapse  and  great  prostration  makes  it  extremely 
hard  to  get  a  surgeon  to  operate. 

Acute  Pancreatitis. 

Remember  that  the  onset  is  sudden  in  stout  adult 
males  with  an  alcoholic  or  gallstone  history. 
Remember  that  the  initial  symptoms  are: 

1.  Epigastric  pain,  usually  severe  and  agonizing, 
and  is  diffused  over  the  epigastric  region. 

2.  Tenderness,  usually  over  the  head  of  the  pan- 
creas, but  may  move  to  the  left  over  the  body  or 
tail.  The  epigastric  region  is  swollen  and  the  recti 
are  tense. 

3.  Collapse  occurs  early,  and  is  an  important 
sign;  often  severe,  and  threatens  immediate  death. 
The  pulse  is  rapid  and  there  may  be  cyanosis. 

4.  Vomiting  is  severe  and  obstinate.  Food,  mucus, 
and,  at  times,  blood  is  brought  up. 

5.  Constipation  is  present,  and  thus  simulating 
intestinal  obstruction,  but  remember  that  flatus  is 
passed. 

Remember  that  intestinal  obstruction  is  less 
severe  in  onset;  there  is  distention  of  the  abdomen, 
which  is  very  rarely  confined  to  epigastric  region, 
and  the  peristaltic  waves  may  be  seen  above  the 
obstruction,  while  blood  and  mucus  will  be  found 
in  the  stool  if  the  obstruction  is  not  complete. 


64  diseases  of  the  pancreas  and  peritoneum. 

Treatment. 

Use  morphin  and  atropin  for  the  pain.  Feed  per 
rectum.  Use  stimulants  freely  in  collapse.  Opera- 
tion is  indicated  if  the  collapse  is  not  too  profound. 

Chronic  Pancreatitis. 

Remember  that  this  occurs  most  frequently  in 
the  fourth  and  fifth  decades  of  life,  at  the  time  when 
malignancy  may  be  expected.  The  onset  is  gradual, 
beginning  as  gradual  emaciation  and  weakness. 
Anorexia,  and  in  some  a  loathing  of  food. 

Remember  that  the  examination  of  feces  reveals 
large  amount  of  pale-colored  passages,  resembling 
the  stools  of  icterus.  Fat  and  muscle  fibers  of  un- 
digested meat  are  found. 

Remember  that  recurrent  attacks  of  epigastric 
pain,  with  bilious  vomiting,  may  occur.  The  pain 
is  referred  to  a  point  a  little  above  the  umbilicus, 
but  does  not  radiate. 

Jaundice  may  occur,  but  it  gradually  deepens, 
and  the  gallbladder  is  distended. 

Palpation  reveals  a  hard  tumor  over  the  head  of 
the  pancreas,  which  may  be  at  times  mistaken  for 
tumor  of  the  gland. 

Remember  that  in  gallstones  the  onset  is  abrupt, 
with  severe  colicky  pains,  that  radiate  to  the  shoul- 
der, and  jaundice,  when  present,  is  not  so  deep, 
while  the  gallbladder  shrinks  and  is  not  palpable. 

Remember  that  glycosuria  is  present  only  in 
those  cases  where  the  islands  of  Langerhans  are  in- 


CHRONIC  PANCREATITIS PANCREATIC  CYSTS.       65 

volved,  but  indican  in  the  urine  is  decreased  be- 
cause of  the  incomplete  digestion  of  the  proteids  of 
the  food. 

Treatment. 

In  severe,  long-standing  cases,  only  operation 
will  give  relief.  Opening  and  draining  the  gall- 
bladder or  anastomosis  is  indicated.  "Where  icterus 
is  present,  calcium  lactate  gr.  xv-3  j  three  times  a 
day  before  operation  increases  the  coagulability  of 
the  blood.  Feeding  extract  of  the  pancreas  is 
thought  by  some  to  be  helpful  in  assisting  in  diges- 
tion of  proteids  and  assimilation  of  fats. 

Pancreatic  Cysts. 

Cysts  are  most  often  found  between  the  twentieth 
and  fortieth  years. 

Remember  that  most  cysts  are  due  either  to 
trauma,  inflammation,  or  impacted  calculi. 

Remember  that  palpation  is  the  method  of  diag- 
nosing cysts,  and  reveals  a  deep-seated,  retro- 
peritoneal swelling  located  in  the  epigastric  region, 
usually  in  the  median  line  or  slightly  to  the  left. 
Inflation  of  the  stomach  and  colon  shows  the  tumor 
lying  between  them.  In  form  it  is  round,  oval,  and 
smooth. 

-  Remember  that  the  tumor  is  immobile;  has  no 
respiratory  movements,  and  very  little,  if  any,  on 
palpation. 

Jaundice  occurs  only  when  a  large  cyst  presses 
on  the  duct  and  is  never  deep.    Vomiting  and  con- 


66    DISEASES  OF  THE  PANCREAS  AND  PERITONEUM. 

stipation,  wlien  present,  is  due  to  the  same  cause. 
Fluctuation  may  be  obtained  in  large  cysts. 

Remember  that  fatty  stools,  containing  undi- 
gested muscle  fibers,  are  not  found  in  all  cases,  but 
are  very  significant  when  they  occur.  Glycosuria 
may  be  present  when  large  portion  of  the  gland  is 
involved. 

Always  obtain  a  complete  history  in  large  abdomi- 
nal cysts,  and  make  a  thorough  physical  examina- 
tion with  patient  in  Trendelenburg  position  in  dif- 
ferentiating pancreatic  and  ovarian  cysts. 

Remember  that  tumor  of  transverse  colon  is  much 
more  superficial  in  location,  and  that  pancreatic 
cysts  have  a  very  remarkable  feature  of  transitory 
disappearance. 

Treatment. 

The  treatment  is  entirely  surgical.  Opening  and 
draining  the  cyst  is  much  the  better,  as  it  gives  a 
much  lower  death  rate. 

Carcinoma  of  the  Pancreas. 

When  the  growth  starts  in  the  head  of  the  pan- 
creas, sooner  or  later  the  duct  is  completely  ob- 
structed with  dilatation  and  retention  cysts  in  tail 
of  the  organ. 

Remember  that  the  common  duct  passes  through 
the  head  of  the  pancreas  or  just  behind  it,  and  the 
hardened  tumor  eventually  produces  obstruction  of 
the  common  duct,  causing  distention  of  the  gall- 


CARCINOMA  OF  PANCREAS.  67 

bladder,  enlargement  of  the  liver,  and  a  severe, 
progressive,  and  permanent  jaundice. 

Pressure  on  the  portal  vein  causes  ascites,  which 
is  often  pronounced,  and  often  edema  of  the  legs 
is  caused  by  pressure  on  the  cava. 

The  bowels  are  irregular,  and  the  striking  fea- 
tures of  the  feces  are  their  pale,  soft,  bulky,  and 
offensive  character  and  the  great  excess  of  fats,  due 
to  the  lack  of  pancreatic  ferments. 

Remember  that  the  rapid  emaciation,  the  loss  of 
strength,  and  anorexia,  with  dyspeptic  symptoms, 
are  present. 

Remember  that  the  intense,  permanent  jaundice, 
with  little  or  no  pain,  and  distended,  palpable  gall- 
bladder exclude  biliary  stones. 

Remember  that  in  interstitial  pancreatitis  the 
history  is  much  longer,  emaciation  less  marked, 
pain  and  tenderness  above  the  umbilicus  more 
common.  In  many  cases  a  hard,  immobile  tumor  is 
palpable  in  the  epigastrium. 

Treatmejstt. 

Treatment  is  palliative.  While  the  distended 
gallbladder  may  be  opened  and  drained,  or  complete 
extirpation  of  the  gland  performed,  it  is  doubtful 
whether  permanent  recovery  follows.  Morphin 
should  be  used  if  there  be  pain.  Rectal  feeding 
should  be  followed  to  keep  up  the  strength  as  long 
as  possible. 


68    DISEASES  OF  THE  PANCREAS  AND  PERITONEUM. 

Acute  Peritonitis. 

Remember  that  Bright 's  disease,  gout,  and  arte- 
riosclerosis are  often  terminated  by  acute  peri- 
tonitis. 

Always  get  a  careful  history  of  previous  condi- 
tion, as  often  a  clew  may  be  had  of  the  starting 
point. 

Remember  that  inflammation  of  the  peritoneum 
is  secondary  to  inflammation  of  contained  viscera 
or  trauma. 

Remember  that  the  mental  condition  of  the  pa- 
tient will  modify  the  symptoms  of  onset. 

Remember  that  shock  is  a  conspicuous  symp- 
tom, announcing  the  onset  of  peritonitis,  and  is  due 
either  to  perforation  or  it  may  occur  later  from 
toxemia. 

Remember  that  the  chief  features  of  the  clinical 
picture  are  pain,  tenderness,  rigidity,  vomiting, 
pulse,  attitude,  and  facies. 

Remember  that,  while  the  pain  is  usually  greatest 
near  the  navel,  yet  the  primary  lesion  may  alter  it 
some — as  in  gastric  perforation  the  pain  may  be 
epigastric  and  in  the  back. 

Remember  that  the  important  thing  about  the  ten- 
derness is  that  it  is  deep  and  not  superficial.  The 
muscular  rigidity  is  the  same  as  found  over  an 
inflamed  appendix,  except  it  is  found  over  all  the 
abdominal  muscles. 

Remember  that  the  pulse  is  rapid,  small,  and 
hard — the  wiry  pulse — occurring  more  often  in  this 


ACUTE    PERITONITIS.  69 

than  any  other  affection.  The  patient  lies  on  his 
back,  with  limbs  drawn  up  and  shoulders  elevated. 

Early,  the  abdomen  may  be  retracted — the 
scaphoid — but  later  is  distended  and  tympanitic. 

Remember  that  the  facies,  Hippocrates'  descrip- 
tion, can  not  be  improved — ''a  sharp  nose,  hollow 
eyes,  collapsed  temples;  the  ears  cold,  contracted, 
and  their  lobes  turned  out;  the  skin  about  the  fore- 
head rough,  distended,  and  parched;  the  color  of 
the  whole  face  being  brown,  black,  livid,  or  lead- 
colored."  Vomiting  occurs  early,  and  soon  be- 
comes bilious  or  even  focal. 

Respirations  are  shallow  and  of  costal  type.  The 
diaphragm  is  high,  liver  and  splenic  dullness  dis- 
appears, and  the  apex  beat  of  heart  pushed  up  into 
fourth  costal  space. 

Remember  that  hysterical  patients  have  so  simu- 
lated peritonitis  as  to  deceive  the  very  elect. 

Remember  that  in  enterocolitis  the  pain  is 
colicky;  there  is  diarrhea  and  tenesmus;  there  is 
collapse,  but  it  is  due  to  rapid  loss  of  water  and 
toxemia. 

Remember  that  in  intestinal  obstruction  there  is 
complete,  sudden  stoppage  of  the  bowels — no  flatus 
passing;  or  there  are  bloody  stools  (depending  on 
the  cause) ;  an  immovable,  tense  mass  at  the  point 
of  obstruction,  which  may  be  seen  or  felt. 

Remember  that  tuberculosis  must  not  be  forgotten 
as  a  causative  factor,  and  that  usually  symptoms  of 
tuberculosis  are  found. 


70  diseases  of  the  pancreas  and  peritoneum. 

Treatment. 

Only  surgical  treatment  is  of  any  value.  Open  the 
abdomen;  repair  the  cause  if  possible;  drain;  put  the 
patient  in  Fowler's  semi-erect  posture,  with  the  con- 
tinuous flow  into  the  rectum  of  hot  saline  solution 
(page  29).  This  procedure  is  now  saving  three- 
fourths  of  these  patients,  which  was  formerly  the 
death  rate. 

Diet.  Allow  nothing  by  the  mouth.  Add  pano- 
pepton  to  the  salt  solution  used  in  the  continuous 
flow. 

Never  be  guilty  of  willingly  treating  acute  peri- 
tonitis medicinally.  There  is  no  valid  reason  for 
doing  so,  and  the  mortality  is  very  high.  Opium, 
or  any  of  its  derivatives,  gives  only  a  false  sense 
of  relief,  and  the  saline  treatment  is  no  better. 


CHAPTER  VI. 

DISEASES  OF  THE  KIDNEYS  AND  BLADDER. 

Movable  Kidney. 

Remember  that  this  is  decidedly  more  common  in 
women  and  frequent  in  hysterical  patients. 

Remember  that  the  di:fference  between  a  palpable, 
movable,  and  floating  kidney  is  one  of  degree. 

Remember  that  palpation  is  the  only  way  a 
diagnosis  can  be  made.  Use  the  following  pro- 
cedure: 

Put  the  patient  in  the  dorsal  position,  with  the 
head  moderately  low  and  the  abdominal  muscles 
relaxed.  Place  the  left  hand  in  the  lumbar  region 
behind  the  eleventh  and  twelfth  ribs.  Put  the  right 
hand  in  the  hypochondriac  region  in  the  nipple  line, 
just  under  the  edge  of  the  liver.  Gently  press  the 
two  hands  together,  when  a  firm,  round  body  may 
be  detected  just  below  the  ribs — this  is  a  palpable 
kidney. 

Have  the  patient  take  a  deep  breath,  when  the 
fingers  may  be  slipped  up  over  the  kidney,  but  the 
organ  can  not  be  pushed  below  the  level  of  the 
navel — a  movable  kidney. 

The  kidney  may  be  grasped  with  the  hand  and 
moved  to  any  part  of  the  abdomen,  or  even  into  the 
pelvis — a  floating  kidney. 

Remember  that  in  a  large  majority  of  cases  there 

71 


72        DISEASES    OF    THE    KIDNEYS   AND    BLADDER. 

are  no  sjTnptoms,  and  the  condition  is  detected  acci- 
d  entail}^,  but  it  is  well  not  to  inform  tlie  patient. 

Eemember  that  dyspeptic  symptoms  in  a  neurotic 
woman  that  do  not  yield  to  ordinary  treatment  are 
probably  due  to  a  displaced  kidney. 

Jaundice,  slight  and  of  short  duration,  but  recur- 
ring frequently,  is  probably  due  to  nephroptosis. 
In  a  floating  kidney  the  kinking  of  the  vessels  by  a 
twisting  of  the  kidney  causes  abdominal  pain, 
chills,  nausea,  vomiting,  fever,  and  collapse.  The 
amount  of  urine  may  be  decreased,  dark,  and  contain 
albumin,  pus,  and  blood,  and  the  kidney  may  be 
tender  and  swollen.  The  skin  is  moist  and  cold; 
at  the  close  of  the  attack  there  may  be  a  copious 
amount  of  pale  urine.  Acute  hydronephrosis  results 
fi"om  strangulation  of  the  ureter.  Worry  and  anx- 
iety may  cause  a  loss  in  weight. 

Treatment. 

The  patient  should  be  confined  to  bed  and  forced 
feeding  resorted  to.  The  object  of  this  is  twofold — 
first,  it  is  the  best  method  of  treatment  for  the 
neuroses  coexisting,  and,  second,  by  putting  on  fat 
the  patient  furnishes  additional  support  for  the  dis- 
placed kidney.  The  kidney  should  be  held  in  its 
normal  place  by  a  well-fitting  bandage  applied  to 
the  abdomen,  with  or  without  a  pad  over  the  dis- 
placed kidney. 

The  following  advice  from  Dr.  Potter  should  be 
heeded:     "A  properly-fitting  bandage  is  not  easy 


MOVABLE   KIDXEY ACUTE    ]N"EPHEITIS.  73 

to  secure,  especially  for  very  thin  patients.  I  rarely 
use  a  pad,  but  attempt  to  secure  the  retention  of  the 
kidney  by  a  well-fitting,  long,  low  corset,  or,  in  more 
difficult  cases,  by  an  elastic  bandage  encircling  and 
sustaining  the  lower  two-thirds  of  the  abdomen. 
The  physician  must  carefully  examine  such  contri- 
vances after  being  applied  and  worn  by  the  patient. 
No  case  should  be  operated  upon,  in  my  judgment, 
until  every  possible  medical  measure  has  been  thor- 
oughly tried." 

The  only  medicine  indicated  is  a  tonic  when  the 
appetite  fails. 

Acute  Nephritis. 

Remember  that  this  condition  may  complicate  any 
of  the  infectious  diseases,  and  frequently  follows 
t}Tphoid  and  scarlatina. 

Always  inquire  about  medicinal  substances  used, 
as  often  the  use  of  potassium  chlorate  tablets,  fre- 
quently used  for  sore  throats,  or  turpentine,  will 
cause  acute  nephritis. 

Remember  that  there  are  two  classes  of  cases — 
one  class  where  the  dropsy  is  extreme,  as  seen  in 
scarlatinal  form,  while  in  the  other  class  there  is 
little  or  no  dropsy. 

Remember  that  acute  Bright 's  disease  may  exist, 
the  anasarca  be  extreme,  but  the  urine  contain  no 
albumin,  or  only  a  trace. 

Remember  uremia  may  be  the  first  symptom,  but 
it  usually  occurs  later. 


74        DISEASES    OF    THE    KIDISTJYS   AKD    BLADDER. 

Always  examine  the  nrine.  It  will  be  dark  and  of 
a  smoky  color;  high  specific  gravity;  small  in 
amount,  and  contain  albumin,  tube  casts,  and  often 
blood  cells. 

Remember  that  pleural  effusions  may  be  large  and 
the  lungs  edematous,  although  dropsy  is  not  exten- 
sive. 

Remember  that  anemia  is  a  prominent  and  early 
sign,  and  gives  a  i^eculiar,  pale  complexion. 

Remember  that  every  urine  containing  abumin  is 
not  a  case  of  acute  nephritis. 

A  peculiarity  of  the  dropsy  in  acute  nephritis  is 
its  irregularity  of  distribution,  and  does  not  always 
gravitate  according  to  the  posture  of  the  patient. 

Always  examine  frequently  the  urine  in  preg- 
nancy, especially  in  cases  complaining  of  occipital 
headache,  or  swelling  of  the  ankles,  or  edema  of 
face. 

Remember  that  it  is  in  syphilitic  nephritis  that 
large  quantities  of  albumin  is  found. 

Teeatmeis't. 

Often  it  is  easy  to  discover  the  etiologic  factor, 
which  should  then  be  treated  rather  than  the  nephri- 
tis. In  cases  due  to  malaria,  quinin  is  indicated, 
while  in  that  form  occurring  in  the  secondary  stage 
of  syphilis,  mercury  will  cause  a  complete  and  per- 
manent subsidence.  The  iodids  are  not  so  bene- 
ficial as  they  are  in  the  tertiary  stage.  In  typhoid 
with  nephritis,  cold  baths  should  not  be  given  on 


ACUTE   NEPHRITIS.  75 

account  of  the  sudden  cooling  of  the  skin,  but  tepid 
sponging  may  be  substituted.  Care  as  to  medica- 
ments used  must  be  observed,  regardless  of  the 
cause,  in  many  cases.  Drugs  causing  renal  irrita- 
tion must  be  abandoned.  Some  of  these  are  tar, 
styrax,  naphthalin,  phenol,  oil  of  turpentine,  potas- 
sic  chlorate,  and  cantharides. 

While  salicylic  acid  and  its  derivatives  cause 
renal  irritation,  they  should  be  used  in  the  treatment 
of  a  causative  articular  rheumatism. 

Symptomatic  Treatment.  The  patient  should  be 
in  bed  and  kept  there  until  all  traces  of  the  disease 
have  disappeared.  Counterirritation  over  lumbar 
area  will  relieve  renal  congestion.  Cantharides  or 
mustard  plaster  should  not  be  used  because  of  renal 
irritation.  Cupping,  wet  or  dry,  leeches,  or  the  appli- 
cation of  the  actual  cautery  applied  to  Petit 's  tri- 
angle, as  the  network  of  veins  here  communicate  di- 
rect with  the  perirenal  veins,  should  be  followed.  In 
severe  cases  of  renal  congestion,  where  there  is 
marked  diminution  of  urine,  many  blood  cells,  and 
severe  lumbar  pain,  headache,  and  vomiting,  the  ap- 
plication of  leeches  every  other  day  and  on  alternate 
days,  dry  cupping  morning  and  night,  until  the 
severe  symptoms  have  subsided,  afford  relief.  The 
quickest  and  probably  the  best  way  of  relieving  the 
congestion  is  by  venesection  performed  on  the  lower 
extremity.  The  vena  pediaea  may  be  opened  and 
10  ounces  of  blood  withdrawn. 

Diet  is  of  supreme  importance.    All  meats  and 


76         DISEASES    OF    THE    KIDNEYS   AND   BLADDER. 

preparations  made  from  meat  must  be  excluded. 
Strictly  milk  diet  is  best.  Buttermilk,  gruels  made 
of  arrow-root,  oatmeal,  barley-water,  butter,  crack- 
ers, and  cream  may  be  allowed.  All  condiments 
and  alcohol  should  be  forbidden.  The  diet  should 
be  salt  (sodium  chlorid),  free,  especially  if  there 
be  much  dropsy. 

Cases  due  to  bacterial  toxin  should  be  given  plenty 
of  water  to  dilute  the  poison  and  reduce  the  renal 
irritation. 

Diuretics.  Alkaline  mineral  waters  should  be 
used  freely.  When  they  fail  to  increase  urinary  se- 
cretion, some  of  the  following  may  be  used  to  ad- 
vantage : 

Caffein  is  excellent  because  it  is  cardiac  as  well 
as  kidney  stimulant.  Never  give  over  10  grains 
daily,  as  15  grains  will  cause  albuminuria. 

IJ     Caff  ein, 

Sodii  benzoatis    aa  gr.  iij 

Misce  et  fiat  eapsula  No.  I.     Dentur  tales  capsulae  No.  XV. 
Sig. :   Capsule  three  times  a  day. 

The  best  form  is  probably  the  double  salt: 

B     Caffein-sodii  salicylatis   gi"-  "j 

Sig.:  One  such  dose  three  times  a  day. 

Potassium  acetate  in  large  doses  is  also  a  good 
diuretic : 

TJ     Potassii  acetatis  3  iv-3  v 

Syriipi  rubi  idsei    §  ss 

Aquse  destillatse   q.  s.  ad  3  vj 

Misce. 

Tablespoonful  every  two  hours. 


ACUTE   NEPHRITIS.  /  / 

In  the  early  stage  the  following  is  a  good  diu- 
retic and  also  equalizes  the  circulation: 

B     Tincturae  aeoniti  TTL  xij 

Spiritus  setheris  nitrosi 3  vj 

Solutio  potassii  citratis   B  i j 

Syrupi  tolutani   q.  s.  ad  §  iij 

Misce  et  flat  solutio. 

Sig. :  Teaspoonful  every  two  hours. 

Or: 

IJ.     Potassii  citratis    5  ss 

Infusi  digitalis   §  j 

Aquae     S  j 

Misee. 

Sig.:  Dessertspoonful  every  three  hours. 

Where  the  heart  needs  stimulating,  the  following 
is  excellent: 

IJ.     Tincturae  digitalis    3  v 

Vini  scillse   §  iss 

Spiritus  setheris  nitrosi    5  ij 

Misce. 

Sig. :  Teaspoonful  every  three  or  four  hours. 

Diaphoretics.  To  increase  the  activity  of  the  skin 
is  to  lessen  the  tension  on  the  kidney.  Hot  baths, 
and  have  the  patient  sleep  between  blankets  dressed 
in  light  flannel  gown.  Pilocarpin  can  be  used  with 
safety  only  in  a  selected  number  of  cases.  It  should 
never  be  given  to  children.  It  is  best  administered 
hypodermatically.  It  is  better  always  to  give 
minimum  dose — say,  gr.  Ks — and  repeat  in  one  hour, 
than  to  give  one  dose  of  gr.  %. 

Purging  should  be  moderate,  but  is  of  great  bene- 
fit. A  good  rule  is,  "purge  one  day  and  sweat  the 
next. ' ' 


78       DISEASES    OF   THE    KIDKEYS   AND    BLADDER. 

A  very  excellent  cathartic  is  the  following: 

B     Pulveris  jalapse  compositse, 

Potassii   bitartratis    aa  3  ss-3  j 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  No.  X. 
Sig. :    1  powder  every  other  morning. 

Chronic  Parenchymatous  Nephritis. 

Remember  that  the  urine  for  the  twenty-four 
hours  is  diminished  in  quantity,  has  a  dark,  smoky 
color,  and  is  turbid  from  the  presence  of  urates. 
The  specific  gravity  is  high,  and  on  standing  a 
heavy  sediment  is  deposited.  Albumin  is  always 
present,  and  is  more  abundant  in  day  than  night 
urine.  The  total  amount  of  solids — as  urea,  phos- 
jjhates,  and  chlorids — is  reduced.  Hyaline,  granu- 
lar, fatty,  and  epithelial  casts  are  abundant. 

Remember  that  edema  is  frequent  and  often  the 
first  symptom  to  attract  attention.  Occurs  first 
about  the  eyes,  and  seen  only  in  the  morning,  but 
later  it  is  permanent  and  becomes  general.  The 
patient's  appearance  is  very  suggestive — puffy  eyes, 
pale  and  swollen  cheeks,  dull  expression,  distended 
abdomen,  and  shapeless  wrists  and  ankles. 

Remember  that  anemia  is  a  prominent  and  pro-, 
nounced  symptom  in  this  form  of  nephritis.     The 
pulse  small,  soft,  and  rapid.    The  apex  beat  weak, 
indicating  dilatation. 

Remember  that  the  first  manifestation  of  long  ex- 
isting trouble  may  be  epileptiform  seizures,  or  an 
attack  of  uremic  dyspnea  simulating  asthma. 

Remember    that    a    general    failure    of    health, 


CHROlSriC   PARENCHYMATOUS   NEPHRITIS.  79 

shown  by  loss  of  energy,  easily  fatigued,  loss  of 
appetite  with  digestive  disturbances,  is  frequently 
found  early  in  this  condition. 

Remember  that  vomiting  occurs  often  in  the 
course  of  renal  trouble,  and  usually  caused  at  sight 
of  or  on  taking  food.  The  nausea  accompanying 
the  vomiting  is  intense. 

Remember  the  examination  of  the  eyes,  as 
albuminuria  retinitis  is  one  of  the  most  character- 
istic features  of  this  form  of  renal  trouble. 

Remember  that  in  many  asthmatic  seizures  the 
trouble  is  caused  by  a  lesion  of  the  kidney,  and  the 
albuminuria  is  causative  and  not  dependent  upon 
the  asthma. 

Teeat^ient. 

Rest  in  bed  is  best.  This  should  be  continued  for 
as  long  a  period  of  time  as  possible,  as  it  reduces 
albuminuria  and  reduces  waste  products  thrown 
upon  the  kidneys  for  excretion.  The  patient  should 
be  dressed  in  canton  flannel,  and  lie  between  blank- 
ets, so  that  the  skin  may  be  kept  active. 

Diet.  Nothing  should  be  allowed  that  increases 
the  work  of  the  kidneys.  Milk  diet  is  excellent,  but 
it  is  impossible  to  administer  enough  to  keep  up 
the  body  nutrition.  Two  to  three  pints  of  milk  dur- 
ing the  day,  to  which  cream  has  been  added,  is  suf- 
ficient. Calcium  carbonate  gr.  v-gr.  x,  administered 
with  the  milk,  precipitates  the  phosphates  and  thus 
prevents  their  being  absorbed  and  irritating  the 


80       DISEASES    OF    THE   KIDNEYS    AND    BLADDER. 

kidneys.  Meat,  as  veal,  mutton  (well  cooked),  and 
beef,  may  be  allowed  restricted.  Carbohydrates  and 
sugar  must  furnish  the  bulk  of  nutrition.  Potatoes, 
rice,  butter,  sugar,  eggs  (cooked),  olive  oil,  and  cod- 
liver  oil  are  all  excellent  in  varying  the  diet.  A 
moderate  amount  of  all  fresh  fruits,  except  cran- 
berries, is  allowable.  Onions,  garlic,  tomatoes,  rad- 
ishes, asparagus,  and  celery  must  be  forbidden, 
while  beans,  peas,  turnips,  carrots,  lettuce,  and 
cauliflower  should  be  given. 

Salt.  Most  nephritics  eliminate  sodium  chloride 
imperfectly,  so  that  much  of  it  is  retained.  Sodium 
chloride  controls  osmosis  in  the  economy.  When 
retained  in  the  blood,  it  becomes  hypertonic  and 
less  water  is  excreted  by  the  skin,  lungs,  and  kid- 
neys. Dropsy  then  begins  or  increases,  as  does 
albuminuria;  hence  a  diet  free,  or  as  near  that  as 
possible,  will  lessen  both  hydrops  and  the  albumin. 

Water.  Care  must  be  exercised  in  the  amount  of 
water  taken.  An  excessive  quantity,  thus  engorg- 
ing the  blood  and  lymph,  and  increasing  the  work 
of  the  heart,  is  just  as  harmful  as  too  little  given. 
About  three  pints  are  an  average  amount  to  be  given 
in  twenty-four  hours. 

Baths.  Lukewarm  or  hot  baths  three  or  four 
times  a  week,  followed  by  a  light  sweat,  are  advis- 
able to  keep  up  the  activity  of  the  skin.  Where 
atheroma  exists,  care  should  be  taken. 

Clothing.  The  feet  must  be  well  protected,  and 
patient  should  wear  woolen  underwear.  A  flannel 
band  over  the  loins,  in  addition,  is  often  beneficial. 


CHROmC    INTERSTITIAL   I^EPHEITIS.  81 

The  Bowels.  These  must  be  kept  open.  If  con- 
stipated, saline  cathartics  should  be  used.  The 
compound  jalap  powder  and  Eochelle  or  Epsom 
salts  are  probably  best.  The  anemia  is  to  be  com- 
bated by  using  iron.  The  syrup  of  the  iodid  of 
iron  or  the  tincture  of  the  chlorid  is  best;  best 
given  half  an  hour  after  meals. 

Diuretics.  Most  of  them  should  not  be  used. 
Cream  of  tartar  3  j  as  a  refrigerant  drink  or  potas- 
sium citrate  gr.  xx-gr.  xxv  are  the  only  safe  ones. 
Liquoris  ferri  et  ammonii  acetatis  3  j-3  ij  ( Bash- 
am 's  mixture)  may  be  given  for  its  tonic  as  well  as 
diuretic  effect. 

Chronic  Interstitial  Nephritis. 

Remember  that  this  is  the  lesion  occurring  in  the 
aged  and  is  intimately  connected  with  arterio- 
sclerosis. 

Remember  that  the  urine  is  greatly  increased  in 
quantity  and  is  voided  so  often,  especially  at  night, 
that  the  patient  usually  seeks  relief  of  so  trouble- 
some a  symptom. 

Always  examine  such  cases  for  enlarged  prostate. 

Remember  that  there  are  three  cardinal  findings 
in  this  condition — cardiovascular,  urinary,  and 
retinal — and  he  who  invariably  examines  the  urine 
and  heart  in  every  instance  rarely  fails  in  his 
diagnosis. 

Remember  that  the  increased  urine  is  pale  in 
color  and  low  in  specific  gravity,  there  is  a  reduction 


82        DISEASES    OF    THE    KIDIS^YS    AND    BLADDER. 

of  solids,  and  albumin  is  found  only  in  trace  and 
may  be  absent  at  times. 

Remember  that  persistent  low  specific  gravity  is 
one  of  the  constant  and  important  features  of  this 
condition;  therefore  frequent  urinary  examinations 
should  be  made. 

Remember  that  the  hypertrophy  of  the  heart 
causes  a  displacement  of  the  apex  beat  downward 
and  to  the  left,  and  the  impulse  is  forcible  and  may 
be  heaving. 

Remember  that  the  pulse  is  not  only  hard,  but  the 
tension  is  increased,  so  that  it  requires  considerable 
pressure  to  overcome  it,  and  when  abolished  the 
vessel  below  can  be  rolled  under  the  finger. 

Remember  that  chronic  bronchitis,  especially  in 
the  winter,  is  common. 

Remember  that  trouble  in  vision  may  be  the  first 
symptom,  and  caused  most  frequently  by  retinal 
hemorrhage. 

Remember  that  edema  is  not  common,  and  when 
it  appears  it  is  due  to  cardiac  failure. 

Treatment. 

Don't  advise  the  use  of  large  amount  of  liquids, 
and  it  is  better  to  restrict  them  to  two  pints  per 
day.  Milk  diet  is  indicated  only  when  uremia 
threatens. 

Remember  that  in  this  form  of  nephritis  it  is 
more  important  to  watch  the  heart  than  the  kidneys. 

Diuretics  should  not  be  used  unless  there  is  a 


chrojs^ic  interstitial  nephritis.  83 

great  diminution  of  quantity  of  urine  or  dropsy  de- 
velops, and  then  only  for  a  short  period  of  time. 
At  first  indication  of  weakening  of  heart,  adminis- 
ter digitalis,  caffein,  camphor,  or  squills  until  there 
is  cardiac  improvement.  Drugs  should  be  carefully 
watched  for  cumulative  action  because  of  slow 
excretion. 

lodids  are  excellent  in  many  cases,  and  are  espe- 
cially indicated  in  syphilitic  nephritis.  Some  of 
the  cases  of  syphilitic  origin  improve  under  mer- 
cury, while  others  are  made  worse,  but  all  respond 
to  iodin  treatment. 

The  dress  should  be  flannel,  and  patient  must  be 
careful  about  catching  cold. 

Iron  is  indicated  if  anemia  is  present — shown  by 
marked  weakness  and  pallor. 

Bowels  should  be  kept  open  by  use  of  salines,  or, 
perhaps  better,  by  alkaline  mineral  waters.  Calomel 
purge  occasionally  is  very  beneficial. 

Skin  should  be  kept  active,  and  this  is  best  done 
by  warm  baths. 

When  the  arterial  tension  is  high,  it  should  be  re- 
lieved because  of  the  danger  of  hemorrhage.  This 
is  best  done  with  nitroglycerin  carefully  adminis- 
tered. Begin  by  giving  1  minim  of  a  1-percent 
solution  (gr.  M.00)  three  times  daily  and  gradually 
increase.  On  the  other  hand,  where  the  tension  is 
low,  as  manifested  by  decreased  amount  of  urine  and 
appearance  of  dropsy,  give  strychnin  or  digitalis. 
The  latter  is  best  given  as  an  infusion. 


84       DISEASES   OP    THE    KIDNEYS   AND    BLADDEE. 

Worry  and  anxiety  must  be  forbidden,  and  patient 
live  a  quiet  life. 

Uremia. 

Remember  tliat  uremia  may  exist  in  a  latent  form. 
The  mind  is  clear  and  pupils  are  contracted,  muscu- 
lar twitchings  and  vomiting  occur,  and  tlie  tempera- 
ture is  subnormal. 

Remember  that  coma  always  accompanies  convul- 
sions, but  it  may  develop  gradually  without  convul- 
sions. 

Remember  that  all  cases  of  intractable  headache, 
either  occipital  or  low  down  in  back  of  the  neck, 
call  for  urinalysis,  that  threatened  uremia  may  not 
be  overlooked. 

Remember  that  muscular  cramp,  particularly  at 
night  in  the  calves,  twitching,  monoplegia  or  hemi- 
plegia, or  tingling  sensations  in  the  limbs,  call  for 
urinalysis  and  the  elimination  of  Bright 's  disease. 

Remember  that  uremic  dyspnea  may  be  continu- 
ous or  paroxysmal,  and  at  times  Cheyne-Stokes 
breathing  may  be  observed.  The  dyspnea  is  usually 
nocturnal,  and  it  is  very  difficult  to  differentiate 
from  true  asthenia  without  the  precaution  of  urin- 
ary examination. 

Remember  that  cerebral  hemorrhage,  meningitis, 
and  brain  tumors  must  be  excluded  in  the  diagnosis. 
The  hemiplegia  is  complete  and  permanent;  vomit- 
ing, tense  pulse,  and  conjugational  deviation  of  the 
eyes  are  present. 


UEEMIA.  85 

In  brain  tumor  may  have  convulsions,  vomiting, 
headache,  vertigo,  with  hemiplegia  or  monoplegia, 
but  in  uremia  these  are  transitory,  while  in  tumor 
they  are  chronic  and  progressive. 

In  meningitis,  when  headache  and  vomiting  are 
followed  by  coma  without  localizing  phenomena, 
and  the  urine  contains  albumin,  spinal  puncture  and 
examination  of  some  of  the  spinal  fluid  is  the  only 
means  of  differentiating  from  uremia. 

Remember  that  uremia  may  last  for  several  weeks, 
and  patient  lie  in  stupor,  with  heavily  coated,  dry 
tongue,  rapid  and  feeble  pulse,  and  muscular 
twitchings,  suggesting  typhoid  or  miliary  tubercu- 
losis. 

In  miliary  tuberculosis  the  pulmonary  signs,  with 
those  of  associated  pleurisy  and  pericarditis,  will 
differentiate,  while  Widal  reaction  of  blood,  rose 
spots,  enlarged  and  soft  spleen,  and  peculiar  tem- 
perature range  will  assist  in  correct  interpretation 
of  the  typhoid  condition. 

Remember  that  in  opium  poisoning  the  pupils  are 
contracted  equally,  while  in  uremia  they  are  not 
constant.  Examine  the  eyes  for  albuminuric  retin- 
itis, and  urinalysis  should  be  made.  The  pulse  is 
slow,  and  respiration  and  the  stupor  are  profound. 
In  coma  from  alcohol  the  unconsciousness  is  not 
so  profound,  and  heavy  pressure  on  the  supraorbital 
nerve  at  junction  of  inner  and  middle  third  of  orbit 
at  the  supraorbital  notch  will  always  cause  a  re- 
sponse.    The   temperature   is   subnormal    and   the 


86       DISEASES   OF   THE   KIDNEYS   AND    BLADDER. 

pupils  usually  dilated.     Place  no  value  upon  the 
odor  of  the  breath  unless  you  know  the  history. 

Remember  that  uremia  occurs  most  frequently  in 
chronic  interstitial  nephritis,  and  that  the  concomi- 
tant vascular  changes  will  be  of  aid  in  diagnosis. 

Treatment. 

In  an  acute  attack  of  uremia  there  is  nothing  com- 
parable to  venesection — withdrawing  half  a  pint 
of  blood  and  replacing  the  amount  by  the  saline 
solution  by  hypodermoclysis.  Never  used  too  early, 
but  often  too  late. 

Diaphoretics.  Pilocarpin  hydrochlorate  gr.  %- 
gr.  Yi  may  be  given  hypodermatically.  If  heart  is 
weak,  give  cardiac  stimulant.  May  be  used  with  hot 
pack. 

Catharsis. 

I^     Elaterini gr-  ^/^ 

Sacchari   lactis    gr.  xv 

Misce  et  fiant  pulveres  No.  V. 

Sig. :  Powder  every  three  hours  until  free  catharsis,  then 
daily. 

Or: 

IJ.     Hydrargyri  chloridi  mitis gr.  viij 

Pulveris  jalapse  compositse 3  iv 

Misce  et  fiant  pulveres  No.  IV. 
Sig.:  Powder  hourly. 

In  case  of  severe  vomiting,  elaterina  hypodermat- 
ically gr.  %0-gr.  %o  may  be  given. 

Cardiac  Tonics.  With  decreased  blood  pressure 
and  small,  thready  or  irregular  pulse,  heart  stimu- 


UKEMIA.  87 

lants  to  raise  pressure  within  the  kidneys  is  ad- 
visable. Digitalis  is  excellent,  but  its  action  is  de- 
layed, so  that  in  acute  cases  it  must  be  reinforced  by 
quicker-acting  stimulants.  Camphor  is  best,  and 
should  be  given  in  large  doses — 3  ij-3  iij  of  a  10-per- 
cent solution  in  olive  oil  hypo  derma tically  during 
the  twenty-four  hours  should  be  given  with  the  digi- 
talis. 

Convulsions  may  be  treated  with  hypodermic  of 
morphin  or  inhalations  of  chloroform.  Venesection 
is  often  very  beneficial  in  this  condition,  or: 

IJ     Chloralis  hydrastis    3  ss 

Potassii   bromidi    3  j 

Tincturae  veratri  veridi TTL  xYTr 

Syrupi  aurantii  florum 3  iv 

Aquae    q.  s.  ad  §  i  j 

Misce. 

Sig. :  Tablespoonful  every  hour  or  two  as  required. 

Or: 

IJ     Pilocarpinse  hydrochloridi    gr.  j 

Tincturae  veratri  veridi *. TTL  xxx 

Syrupi  tolutani 3  iv 

Aquae  anisi   q.  s.  ad  §  j 

Misce. 

Sig.:  Teaspoonful    in   water,    repeated    in    two    or    three 
hours,  as  required. 

Vomiting.  This  is  frequently  persistent  and  ob- 
stinate. The  following  formulae  will  indicate  the 
best  line  of  treatment: 

IJ     Cerrii  oxalitis   gr.  xv 

Sacchari  lactis    3  ss 

Misce  et  divide  in  pulveres  No.  VI. 
Sig.:  Powder  every  three  or  four  hours. 


5b       DISEASES   OF    THE    KIDNEYS   AND    BLADDER. 

Or: 

IJ     Hydrargyri  cliloridi  mitis    gr.  j-gr.  ii j 

Cerrii  oxalitis   gr.  xx 

Saccliari   lactis    gr.  xxx 

Misce  et  divide  in  pulveres  No.  X. 

Sig. :  Powder  every  hour  on  tongue. 

Ingliivin  gr.  v,  administered  every  two  hours,  is 
often  good. 

IJ     Creosoti gtt.  x 

Emulsio  amygdalae B  iss 

Syrupi  simplicis   3  iv 

Misce  et  fiat  emulsio. 

Sig.:    Dessertspoonful   every  four  hours. 

Lavage  of  the  stomach  with  water  at  105°  is  ex- 
cellent and  should  be  tried  early. 

Diarrhea.  Don't  be  too  anxious  to  check  it.  This 
is  one  of  nature's  methods  of  ridding  the  economy  of 
toxic  material. 

Uremic  Asthma.  Spirits  of  ether  gtt.  x-gtt.  xxx 
on  sugar  several  times  a  day.    Or: 

IJ     Extraeti  valerianse   gr.  v-gr.  x 

Dentur  tales  doses  No.  XXX.     Inclosed  in  capsule. 
Sig.:   Capsule  four  or  five  times  daily. 

Diet.  In  an  acute  attack,  starvation  or  Renon's- 
water  diet,  one  quart  to  three  pints  daily,  with  or 
without  lactose,  for  two  or  three  days,  gives  best 
result. 

In  subacute  form  a  diet  similar  to  that  of  Bright 's 
disease  is  best.  In  chronic  form  the  diet  varies  and 
depends  upon  the  urinary  findings. 

Dilute  hydrochloric  acid,  giving  from  one  to  three 


UEEMIA PYELITIS.  89 

teaspoonfuls  in  the  twenty-four  hours,  is  excellent, 
and  probably  is  indicated,  as  many  cases  show  hypo- 
acidity.   To  be  given  following  meals. 

Pyelitis. 

Remember  that  the  great  danger  in  cystitis  is 
pyelitis  by  extension  along  the  ureters. 

Remember  that  pain  in  the  back  or  tenderness  on 
deep  pressure  over  the  affected  kidney,  with  pus  in 
the  urine  and  fever  of  the  septic  type,  are  indicative 
of  pyelitis.  The  pyuria  may  be  intermittent,  due  to 
the  plugging  of  the  ureter  of  the  affected  side. 
When  this  occurs,  the  intermittency  excludes  cys- 
titis. Coincident  with  the  retention,  often  a  tumor 
mass  may  be  felt  on  the  affected  side. 

Remember  that  the  reaction  of  the  urine  is  usually 
acid,  unless  cystitis  coexists. 

Remember  that  in  cystitis  the  pain  is  over  the 
bladder  and  is  made  worse  in  the  erect  posture. 

Remember  that  painful,  frequent  micturition  and 
an  alkaline  urine  suggest  cystitis. 

Remember  that  in  chronic  cases  of  pyelitis,  poly- 
uria and  a  low  specific  gravity  are  usual. 

Remember  that  an  infection  may  extend  to  the 
ureter  from  the  bladder. 

Treatment. 

Diet.  In  the  acute  cases  it  should  be  exclusively 
milk.  The  chronic  cases  should  have  diet  used  in 
nephritis. 


90        DISEASES    OF    THE    SIDNEYS   AJSTD    BLADDER. 

Baths.  A  warm  bath  should  be  given  two  or  three 
times  a  week,  and  the  patient  should  be  carefully 
guarded  against  catching  cold. 

Congestion  is  best  relieved  by  applying  leeches 
over  Petit 's  triangle,  as  the  veins  of  this  region 
communicate  with  those  of  the  renal  capsule.  Free 
catharsis  should  be  employed,  both  for  the  conges- 
tion and  ridding  the  body  of  toxins.  The  vegetable 
cathartics  are  best. 

Pain  may  be  relieved  by  hot  applications  over  the 
affected  kidney,  or,  if  severe,  by  atropin  and  mor- 
phin. 

Antiseptics  are  indicated  to  combat  the  infection. 
Urotropin  is  best,  but  benzoic  acid  or  the  sodic  salt 
may  be  used.  The  action  of  urotropin  is  enhanced 
when  it  is  combined  with  salol. 

R     Urotropini, 

Salolis    aa  9  iiiss 

Misce.     Dentur  tales  doses  No.  XXV.    Inclosed  in  capsule. 
Sig. :   Capsule  every  three  or  four  hours. 

A  capsule  containing  gr.  iss-gr.  iij  of  methylene 
blue  may  be  given  three  times  daily.  Gastric  dis- 
turbances must  be  watched  for. 

I^     Acidi  benzoic!    gr.  ij-gr.  v 

Fiat  tabella  No.  I.     Dentur  tales  doses  No.  XX. 
Sig.:   Tablet  every  two  hours. 


Or; 


I^     Sodii  benzoatis   3  j 

Extracti  gentianae q.  s. 

Misce  et  fiant  pilulae  No.  XXX. 
Sig. :  2  pills  every  two  hours. 


PYELITIS HYDEONEPHEOSIS.  91 

Or: 

B     Sodii  benzoatis   5  j 

Syrupi  rubi  idsei, 

Aquae  menthaB  piperitse aa  3  vj 

Misce. 

Sig. :  Tablespoonfal  two  hours  after  meals. 

Astringents.  Lime  water,  2  to  3-ounce  doses  three 
or  four  times  a  day,  diluted  with  an  equal  quantity 
of  milk,  is  excellent. 

IJ     Plumbi  acetatiSj 

Pulveris  opii aa  gr.  xxx 

Extract!  glycyrrhizse   q.  s. 

Misce  et  fiant  pilulse  No.  XXX. 

Sig.:  1  or  2  pills  three  or  four  times  daily. 

Hydronephrosis. 

Remember  that  this  may  be  congenital,  and  either 
unilateral  or  bilateral.  If  bilateral,  death  results  in 
a  short  time. 

Remember  that  in  many  cases  the  obstruction  is 
intermittent,  and  when  the  obstruction  is  relieved 
there  will  be  a  large  quantity  of  urine  with  the  dis- 
appearance of  the  renal  tumor. 

Remember  that  when  the  tumor  is  of  moderate 
size  it  may  be  palpated  in  the  renal  region,  but 
those  of  extreme  size  may  be  mistaken  for  ascites  or 
ovarian  cysts. 

Aspiration  furnishes  conclusive  evidence.  The 
fluid  aspirated  will  be  clear,  of  low  specific  gravity, 
with  urea  and  urinary  salts. 

Remember  that  in  the  history  the  location  of  the 
tumor  in  the  beginning  is  important,  as  ovarian 


92        DISEASES    OF    THE    KIDNEYS   AISTD    BLADDER. 

tumors  originate  in  the  pelvis.  Ovarian  tumors  are 
movable,  while  hydronephrotic  tumors  are  not,  un- 
less they  occur  in  a  movable  kidney. 

Treatment. 

Cases  of  intermittent  hydronephrosis  causing  no 
serious  symptoms  should  be  let  alone.  When  the 
tumor  becomes  large,  aspiration  should  be  done;  the 
needle  passed  through  the  flank  half  way  between 
the  crest  of  the  ilium  and  the  last  rib.  When  the 
tumor  recurs,  it  may  be  incised  and  drained.  Re- 
moval of  the  kidney  should  be  done  only  as  a  last 
resort.  Sometimes  the  wearing  of  a  pad  and  band- 
age following  aspiration  will  prevent  refilling. 

Nephrolithiasis. 

Depending  upon  the  size  of  the  concretion,  we 
have  sand,  gravel,  or  stone. 

Remember  that  all  stones  are  due  to  a  deposit 
upon  a  framework  consisting  of  albuminous  sub- 
stance and  at  times  epithelial  cells. 

Pain.  Renal  stones  cause  pain.  The  character 
of  the  pain  depends  upon  the  location  of  the  stone." 
Pain,  dull  in  character,  is  felt  in  the  loin,  frequently 
associated  with  local  tenderness,  with  the  stone  in 
the  renal  pelvis.  Certain  movements  which  shake 
the  body  make  it  worse. 

Remember  that  this  dull  pain  and  localized  ten- 
derness may  be  found  without  any  urinary  changes. 

Remember  that  renal  colic  is  caused  by  passing  of 


NEPHROLITHIASIS.  93 

stone  into  the  ureter.  Pain  of  renal  colic  is  sharp 
and  lancinating,  radiating  from  the  renal  region 
along  the  nreter  to  the  bladder,  testis,  labia,  or 
urethra.  The  testicle  is  retracted.  The  kidney  is 
sensitive;  there  is  a  continuous  desire  to  urinate,  but 
can  pass  only  a  few  drops  of  a  concentrated,  bloody 
urine  full  of  sediment.  The  general  symptoms  are 
nausea,  vomiting,  cold  perspiration,  chills,  weak 
pulse;  the  dorsal  posture  is  assumed,  legs  drawn  up, 
and  the  abdominal  wall  rigid.  The  pain  is  greatest 
as  the  stone  passes  into  the  bladder,  as  the  caliber 
of  the  ureter  is  smaller  at  this  point.  The  attack 
ceases  abruptly  on  the  passing  of  the  stone  from  the 
ureter,  either  into  the  bladder  or  back  into  the  renal 
pelvis.  After  the  passage  of  the  stone  a  profuse 
discharge  of  urine  follows. 

Remember  that  the  absence  of  hematuria  after  a 
renal  colic  speaks  strongly  against  a  diagnosis  of 
renal  calculi. 

Remember  in  vesical  calculi  the  pain  is  concen- 
trated over  the  bladder,  and  when  it  radiates  to  the 
flanks  it  is  felt  on  both,  sides.  The  sudden  stoppage 
of  the  flow  in  micturition  and  the  positive  informa- 
tion obtained  by  examining  the  bladder  with  a  stone 
searcher  will  assist  in  differentiating.  The  x-ray  in 
competent  hands  is  of  great  assistance,  but  is  not 
to  be  absolutely  relied  upon.  "While  negative  find- 
ing does  not  absolutely  exclude  stone,  the  per- 
centage of  errors  is  small. 


94     diseases  of  the  kidneys  and  bladder. 

Treatment. 

Renal  Colic.  Prompt  immersion  in  hot  bath,  110° 
to  115°,  for  half  an  hour  often  affords  relief,  but,  if 
it  does  not,  give  while  in  the  bath  hypodermic  of 
morphin  sulphate  gr.  ^-gr.  ^  with  atropin  sulphate 
gr.  Mso-gr.  Ygo,  and,  if  it  fails  to  relieve  the  pain, 
repeat  the  morphin  in  one  hour;  no  relief  following 
this,  give  inhalations  of  chloroform  to  slight  anes- 
thesia. It  is  essential,  to  further  treatment,  that 
careful  watch  be  kept  to  detect  sand  or  gravel  in 
the  urine,  so  that  the  kind  of  stone  may  be  deter- 
mined— whether  uratic,  oxalate,  or  phosphatic.  In 
uratic  or  oxalate  stones  the  acidity  of  the  urine 
must  be  reduced.  For  this  purpose  alkalies  are 
given. 

The  following  effervescent  powder  is  good: 

R     Lithii   carbonatis    gr.  iv 

Sodii   bicarbonatis    gr.  v 

Misce  et  fiat  pulvere  No.  I. 
No.  1. 

R     Acidi   citrici     gr.  viij 

No.  2. 

Dentur  tales  doses  Nos.  1  and  2  No.  X. 
Sig. :    1    of   each   powder   in   half   a   glass  of  water  three 
times  daily;   drink  while  effervescing. 

Glycerin  in  large  doses  is  highly  recommended 
in  assisting  in  passage  of  the  stone. 

R     Glycerini, 

Succi    limonis     aa  §  j 

Misce. 

Sig.:  4  tablespoonfuls  daily. 

Or  put  1  ounce  of  glycerin  into  1  quart  of  lemon- 
ade and  give  during  the  day. 


NEPHEOLITHIASIS.  95 

IJ     Potassii    acetatis    3  iij 

Aquse    cinnamomi    q.  s.  ad  5  ij 

Misce. 

Sig. :   Teaspoonful  every  two  or  three  hours    until    urine 
is  only  slightly  acid. 

Or: 

IJ     Lithii  citratis   gr.  xx 

Sodii  citratis  3  ij 

Aquae    q.  s.  ad  §  ij 

Misce. 

Sig.:    Teaspoonful    in    carbonated    water    every    two    or 
three  hours  until  urine  is  only  slightly  acid. 

Or: 

IJ     Sodii  benzoatis   3  iss 

Syrupi  tolutani    3  v 

Aquse  destillatse   q.  s.  ad  §  vj 

Misce. 

Sig.:  Tablespoonful  every  two  hours. 

As  a  preventive  of  urate  deposit  the  following 
may  be  used: 

IJ     Magnesii  carbonatis 3  j 

Acidi   citrici    3  ij 

Sodii  biboratis    3  ij 

Aquae q.  s.  ad  B  vii  j 

Misce. 

Sig.:    Teaspoonful  three  times  daily. 

Calcium  carbonate  influences  the  monosodium 
and  disodium  phosphates  in  such  a  way  that  the 
urine  can  hold  a  greater  quantity  of  uric  acid  in 
solution  without  losing  its  acid  reaction. 

IJ     Calcii  carbonatis    gr.  x 

Lithii   carbonatis    gr.  j-gr.  ij 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  doses  iSTo.  XX. 
Sig.:  Powder  every  three  hours  with  glass  of  water  until 
urine  only  slightly  acid;  then  three  or  four  times  a  day. 


96       DISEASES   OP   THE    KIDNEYS   AND    BLADDER. 


Or: 


IJ.     Urotropini    3  j 

Misce  et  fiant  pulveres  No.  X. 
Sig. :  Powder  three  times  daily. 

Or: 

R     Magnesii  borocitrici    3  iss 

Sacchari  lactis    3  iiss 

Olei   limonis    TTL  xv 

Misce  et  fiat  pulvere  No.   I.     Dentur  tales  doses  No.  X. 

Sig.:    Powder  three  times  daily  in  a  glass    of    sweetened 
water. 

Diet.  The  diet  for  uric  acid  stones  is  very  im- 
portant. A  mixed  diet,  with  a  preponderance  of 
vegetables,  fats,  and  carbohydrates,  and  occasion- 
ally a  period  of  absolutely  no  meat,  is  indicated. 

Meats.  Avoid  all  kinds  of  meats  that  are  rich 
in  cell  nuclei,  such  as  liver,  brain,  sweetbreads, 
and  kidneys.  The  best  method  of  preparation  is 
by  boiling,  especially  by  putting  the  meat  into  cold 
water  first. 

Fruits.  Are  exceedingly  good  for  patients  suf- 
fering with  uric  acid  excess.  The  vegetable  acids 
are  changed  to  carbonates  and  combine  with  uric 
acid,  forming  urates,  and  these  are  much  more  solu- 
ble in  the  urine. 

The  therapy  of  phosphatic  deposits  differs  con- 
siderably from  the  foregoing.  The  urine  is  usually 
alkaline,  and  contains  abundant  crystals  of  triple 
phosphates. 

Mineral  acids  are  indicated  unless  there  is  a  co- 
existing hyperacidity  of  the  stomach. 


NEPHEOLITHIASIS.  97 

IJ     Acidi  phosphorici    or   hydrochloric! 

diluti    3  iss 

Syrupi  rubi  idaei 3  iv 

Aquae  destillatse  q.  s.  ad  g  vj 

Misce. 

Sig. :    Teaspoonful  in   a  glass   of  water  often   enough   to 
use  the  whole  amount  during  the  day. 

Where  fermentation  occurs  in  the  digestive  tract 
we  must  use  the  antifermentatives. 

IJ     Sodii   boratis    gr.  xx-gr.  xxx 

Syrupi   althaeae    3  v 

Aquas   destillatse    q.  s.  ad  5  vj 

Misce. 

Sig.:  Tablespoonful  every  two  hours. 

Or: 

3     Urotropini    3  iiss 

Aquae  destillatse    5  v 

Misce. 

Sig. :  Tablespoonful  in  a  glass  of  water  to  be  taken  gradu- 
ally during  the  day. 

Or: 

3     Resorcinolis    ( Merck )    gr-  x 

Saechari     gr.  x 

Olei  menthsc  piperitse    gtt.  i j 

Misce  et  flat  cachet  No.  I.     Dentur  tales  cachets  amylaceae 
No.  XX. 

Sig.:  Cachet  three  times  daily. 

Always  treat  the  faulty  condition  back  of  the 
calculus  formation,  such  as  dypepsia,  hyperacidity, 
neurasthenia,  etc.  Have  patient  use  large  quan- 
tity of  water  to  keep  the  kidneys  flushed  out. 

Surgery.  Where  a  stone  becomes  lodged  in  the 
ureters  and  can  not  be  passed  either  into  the  blad- 
der or  back  into  the  renal  pelvis,  or  where  a  large 
stone  forms  in  the  pelvis  too  large  to  embark  upon 


98       DISEASES   OF   THE    KIDNEYS   AND    BLADDEK. 

the  journey  to  the  bladder,  surgery  offers  the  only 
relief,  and  such  cases  should  be  turned  over  to  a 
competent  surgeon. 

Cystitis. 

Remember  that  cystitis  is  probably  in  all  in- 
stances due  to  bacteria.  The  alkalinity  of  the  urine 
is  due  to  the  power  of  many  of  the  bacteria  to 
break  up  urea  into  ammonia  compound.  Urinalysis 
shows  alkaline  urine  as  a  rule;  mucus,  pus,  and 
leucocytes  more  or  less  abundant;  and  crystals  of 
the  trijole  phosphates. 

Remember  that  the  walls  of  the  urinary  bladder 
may  become  so  thickened  that  it  can  be  felt  as  a 
globular,  hard  tumor,  and  hypertrophied,  muscular 
bands  detected  by  the  sound. 

Remember  that  when  a  stone  is  the  cause  of  the 
cystitis,  hematuria  is  more  common;  sudden,  fre- 
quent interruption  of  the  stream  in  micturition,  due 
to  obstruction  of  neck  of  bladder,  and  pain  and 
strangury  at  the  close  of  micturition.  The  explo- 
ration of  the  bladder  with  a  sound  will  confirm  the 
presence  of  the  stones. 

Remember  that  the  examination  of  the  bladder 
with  the  cysto scope  is  important — not  only  in  the 
diagnosis  of  cystitis,  but  the  cause  is  frequently  re- 
vealed. 

Remember  that  in  tubercular  cystitis  without  the 
presence  of  other  organisms  the  urine  is  acid  in  re- 
action, as  the  tubercle  bacilli  do  not  decompose  urea. 


cystitis.  99 

Teeatment. 

Cystitis  due  to  the  presence  of  calculus  can  be 
cured  only  by  removing  the  stone.  Probably  the 
best  method  is  through  the  perineum.  Never  at- 
tempt to  crush  a  stone  in  the  bladder. 

Urinary  antiseptics  are  indicated  in  all  cases,  and 
the  best  is  hexamethylenamine  (urotropin),  given 
in  5-grain  doses  three  or  four  times  a  day.  It  les- 
sens the  probability  of  complicating  pyelitis. 

The  bladder  should  be  irrigated  daily  with  hot 
boracic  acid  solution. 

Diet.  Should  consist  principally  of  milk.  Alco- 
hol, condiments,  and  drugs  that  irritate  the  bladder 
— such  as  cantharides  or  copaiba — must  be  pro- 
hibited. 

Catharsis.  The  bowels  must  be  kept  free,  and 
salines  are  best,  or  oil  enemata  may  be  used. 

Pain.  Hot  applications  should  be  applied  over 
the  pubis.  Cloths  wrung  out  of  hot  water,  and  cov- 
ered with  rubber  cloth  and  bandage,  may  be  used, 
or  hot  flaxseed  poultice.  In  some  cases  the  appli- 
cation of  the  ice  bag  affords  greater  relief.  In  case 
these  local  applications  fail  to  give  relief,  a  hypo- 
dermic of  morphin  gr.  ^  and  atropin  gr.  %oo  should 
be  given  into  the  skin  of  the  abdomen.  Supposi- 
tories may  be  used,  as : 

IJ     Extract!  opii  gr.  vj 

Extract!   hyoseyaminae    gr.  v 

Olei  theobromatis q.  s. 

Misce  et  fiant  suppositoria  No.  VI. 
S!g. :  Insert  1  at  bedtime. 


100      DISEASES   OF  THE    KIDNEYS   AND    BLADDER. 


Or: 


B     Pulveris    opii    gr.  xi j 

Camphorse    gr.  xxx 

Extracti   belladonnse    gr-  iij 

Olei   theobromatis    q.  s. 

Misee  et  fiant  suppositoria  No.  VI. 

Sig. :  Insert  1  at  bedtime. 

Or: 

IJ     Ichthyolis     3  iss 

Aquae  destillatse    0  i j 

Misce. 

Sig.:    Inject  into  the  bladder,   slowly,  warm,    three   times 
daily,  later  once  daily,  as  irrigation. 

Or: 

I^     Fluidextracti  belladonnse    TTt  xx 

Sodii  biboratis    3  ij 

Acidi    benzoici    3  j 

Tincturse  opii  camphoratse   §  iss 

Olei  gaultheriae  TTL  xij 

Syrupi  tolutani §  i  j 

Aquse  destillatse    §  iv 

Misce. 

Sig.:    Dessertspoonful    in   water   four   times  daily. 

Or: 

IJ     Forma  tropini    (Milliken)    §  iij 

Sig.:    Teaspoonful  three  times  daily  after  meals. 

In  the  chronic  form,  irrigation  with  silver  solu- 
tion gives  best  results.  Kaufmann's  plan  for  using 
silver  nitrate  is  best.  Wash  out  the  bladder  with  a 
warm  boracic  acid  solution  and  completely  empty 
it.  The  catheter  is  then  partly  withdrawn,  so  that 
the  silver  solution  may  reach  the  prostatic  portion. 
A  solution  of  silver  nitrate  1:2000  is  injected  and 
retained  for  three  minutes,   and   then  allowed  to 


CYSTITIS.  101 

flow  out  spontaneously.  If  patient  is  very  sensitive, 
this  may  be  followed  by  salt  solution.  After  two 
or  three  days  this  procedure  is  repeated,  using 
1:1000  solution  of  silver  nitrate.  After  this,  1:500 
solution  may  be  used.  The  time  between  injections 
is  gradually  increased  as  improvement  is  noted. 

When  the  urine  is  acid  the  following  combination 
may  be  administered  internally: 

IJ     Potassii    acetatis    3  iv 

Liquoris  potassii 3  j 

Fluidextracti   uva   ursi    3  iv 

Tincturse  hyoscyaminse    3  iv 

TinctursB  lupulini    3  iv 

Aquse     §  i  j 

Syrupi   zingiberis    q.  s.  ad  §  vii j 

Misce. 

Sig. :    Tablespoonful   in   water  after  meals    and    at    bed- 
time. 

Causal  Therapy.  Occasionally  malarial  infection 
will  cause  a  severe  acute  cystitis,  and  quinin  will 
give  prompt  relief  when  other  forms  of  treatment 
fail. 


CHAPTER  \T[. 

DISEASES  OF  THE  BLOOD. 

Chlorosis. 

Remember  that  this  condition  is  due  to  a  de- 
ficiency of  hemoglobin,  and  is  seen  in  girls  at  the 
age  of  profound  sexual  changes.  There  is  no  loss 
of  subcutaneous  fat,  but,  on  the  contrary,  fat  may 
be  increased,  due  to  deficient  oxidation. 

Remember  that  puffiness  of  the  face  and  swelling 
of  the  ankles  may  occur,  and  suggest  nephritis,  but  a 
blood  and  urinary  examination  will  disclose  the 
cause. 

Remember  that  in  some  cases  the  cheeks  may  have 
a  reddish  tint,  and  on  exertion  the  patient  may 
complain  of  palpitation  and  breathlessness,  sug- 
gesting disease  of  the  heart  or  lungs. 

Don't  mistake  the  systolic  murmur  heard  at  the 
apex  for  mitral  disease.  Cardiac  enlargement  is 
absent. 

The  venous  hum  heard  over  the  large  veins  in 
the  neck  is  heard  only  in  anemia. 

Remember  that  a  drop  of  blood  allowed  to  fall 
on  a  piece  of  white  blotting  paper  often  shows  the 
anemia  by  its  pale  color,  due  to  the  reduction  of 
hemoglobin. 

Remember  the  capricious  appetite  in  these  cases 
— the  craving  for  unusual  foods,  especially  acids, 

102 


CHLOEOSIS.  103 

Remember  that  hyperacidity  of  the  stomach  and 
attacks  of  cardialgia,  or  severe  paroxysmal  head- 
aches, are  quite  common  in  chlorosis. 

Remember  that  the  microscope  shows  small,  pale- 
red  cells,  with  but  slight,  if  any,  reduction  in  the 
number. 

Remember  that  in  tuberculosis  there  is  a  pallor, 
but  with  cough;  wasting,  positive  physical  signs, 
rapid  pulse;  slight  fever,  recurring  about  the  same 
time  each  day,  also  coexists;  while  the  pallor  of 
chlorosis  is  yellowish-green,  with  areas  of  pigmen- 
tation, and  the  eyes  jDeculiarly  brilliant,  with  sky- 
blue  sclera. 

Teeatmext. 

Plenty  of  fresh  air  and  good  red  beefsteak  for 
chlorosis  is  an  old  adage  that  is  hard  to  improve 
upon  in  the  treatment. 

Rest  in  bed  is  imperative  in  the  severe  cases,  and 
often  better  results  are  observed  in  milder  attacks 
by  requiring  midday  rest  of  the  patient. 

Exercise  should  be  moderate  and  carefully  regu- 
lated. Those  forms  that  are  passive  to  the  patient 
are  best,  as  buggy  riding  or  boating;  then,  as  im- 
provement occurs,  horseback  riding  and  walking 
may  be  advised. 

Massage  and  dry  rubs  are  excellent.  Electricity 
is  indicated,  and  should  be  used  in  the  severer 
forms  when  neurasthenia  is  a  pronounced  factor. 

Diet  must  be  nutritious.  Proteids  must  be  al- 
lowed liberally.     It  is  best  to  feed  frequently  in 


104  DISEASES    OF    THE    BLOOD. 

small  quantities.     Milk,  to  which  is  added  cream, 
raw  or  slightly  cooked  meat,  and  eggs  are  excellent. 
Constipation  must  be  overcome.     Saline  cathar- 
tics or  iDilulse  aloes  et  f  erri  3  to  5  a  day  may  be  used. 

IJ     riuidextracti  rhamni  pursManse  aro- 

matici   5  j 

Fluidextracli  glycyrrhizse 3  ij 

Misce. 

Sig. :  Teaspoonful  night  and  morning  with  a  glass  of  hot 
■water. 

Where  the  constipation  is  due  to  atony  of  the 
bowels,  and  it  most  frequently  is,  the  following  is 
a  good  combination: 

IJ     Extracti  rhamni  purshianse   3  j 

Extracti  nucis  vomicae gr.  vii j 

Extracti  physostigmatis   gr.  i j 

Extracti  hyoscyaminae   gr.  v 

Misce  et  fiant  pilulse  No.  XXX. 

Sig. :  Pill  night  and  morning. 

Iron  is  the  only  remedy  with  which  to  treat  chlo- 
rosis. The  mode  of  action  is  unknown.  It  is  best 
to  gradually  increase  the  dose  at  the  beginning  and 
gradually  decrease  at  the  close.  Of  the  prepara- 
tions to  be  used,  those  of  U.  S.  P.  are  unexcelled. 
The  vegetable  iron  preparations  have  no  advantage, 
and  the  same  may  be  said  of  peptonates.  All  are 
agreed  that  Blaud's  mass  will  probably  give  best 
results. 

B     Piltilte  ferri  carbonatis   (Blaud),  re- 
cently prepared gr.  v 

Fiat  pilula  No.  I.     Dentur  tales  pilulse  No.  L. 
Sig.:   Pill  three  or  four  times  daily  half  an  hour  before 
meals. 

Blaud's  pills  may  be  given  after  meals,  with  in- 


CHLOROSIS.  105 

crease  of  dose;  for  instance,  1  pill  three  times  daily 
for  the  first  week,  2  during  the  second,  3  during  the 
third,  2  during  the  fourth,  and  1  during  the  fifth. 
It  is  well,  where  there  is  digestive  disturbance,  to 
give  the  following  powder  before  meals: 

IJ.     Betanaphtolis     gr.  j 

Bismuthi  subnitratis, 

Sodii   bicarbonatis    aa  gr.  iiss 

Misce  et  flat  pulvere  No.  I.     Dentur  tales  doses  No.  XX. 
Sig. :  Powder  three  times  daily  before  meals. 

When  severe  attacks  of  gastralgia  occur,  it  is 
usually  made  worse  by  iron  and  interferes  with  the 
treatment.  Use  an  exclusive  milk  diet,  hot  cloths 
over  the  abdomen,  and  administer  either  bella- 
donna or  silver  nitrate. 

IJ     Argenti  nitratis    gr.  x 

Kaolini   gr.  xlv 

Petrolati     q.  s. 

Misce  et  fiat  massa  et  divide  in  pilulse  No.  L. 

Sig.:    Pill  before  meals  three  times  daily. 

Other  forms  of  iron  may  be  used: 

IJ     Ferri  reducti   3  ss 

Pulveris  glyeyrrhizse   3  ss 

Extracti  gentianse    q.  s. 

Misce  et  fiat  massa  et  divide  in  pilulse  No.  XXX. 
Sig.:  Pill  three  or  four  times  daily. 

Arsenic  is  a  useful  drug  in  treating  anemia,  and 
may  be  advantageously  combined  with  the  iron: 

IJ     Ferri  et  ammonii  citratis    §  j 

Liquoris    potassii    arsenitis    3  v 

Aquae  menthse  piperitse    ....  q.  s.  ad  5  vj 
Misce. 

Sig. :  Half  a  teaspoonful  after  meals,  gradually  increasing 
dose  until  teaspoonful  is  taken. 


106  DISEASES    OF    THE    BLOOD. 

Or: 

B     Ferri  et  quininse  citratis  gr.  1 

Elisiris  simplicis    §  ij 

Misce. 

Sig. :    Teaspoonful   three  times   daily. 

It  is  well  to  insist  on  plenty  of  water  with  the 
iron,  especially  iron  in  solution. 

Pernicious  Anemia. 

Remember  that  this  pathological  condition  makes 
its  approach  in  so  slow  and  insidions  a  manner  that 
the  patient  is  unable  to  fix  a  date  of  onset  of  that 
languor  which  later  becomes  such  a  prominent 
symptom. 

Remember  that,  while  the  yellow  color  of  the  skin 
may  indicate  jaundice,  the  sclera  of  the  eyes  re- 
mains white  and  no  bile  pigment  is  found  in  the 
urine. 

Remember  that  the  initial  symptoms  are  failing 
strength,  anorexia,  dyspepsia,  and  intestinal  disor- 
der that  may  be  so  severe  as  to  lead  to  a  suspicion 
of  grave  pathological  lesion  in  the  alimentary 
canal,  and  loss  of  flesh,  but  the  body  maintains  its 
plumpness,  due  to  the  accumulation  of  subcutane- 
ous fat. 

Remember  that  in  some  cases  the  nervous  symp- 
toms are  the  first  to  attract  attention — such  as 
tingling  in  the  fingers,  pains  in  the  back  and  limbs, 
or  the  signs  of  spastic  paraplegia,  tabes  dorsalis, 
or  peripheral  neuritis.  These  symptoms  may  be 
so  pronounced  that  months,  or  even  years,  elapse 
before  the  blood  condition  is  suspected. 


PERNICIOUS   ANEMIA.  107 

Remember  the  circulatory  disturbances — such  as 
palpitation,  faintness  or  actual  syncope,  throbbing 
in  the  head,  buzzing  noises  in  the  ears. 

The  pulse  is  quickened  and  greatly  affected  by 
slight  exertion.  A  blowing  systolic  murmur  is 
heard  over  the  whole  cardiac  area,  but  loudest  in 
the  second  left  intercostal  space  close  to  the 
sternum.  That  it  is  of  hemic  origin  is  proven  by 
the  presence  of  a  similar  murmur  in  the  large  ar- 
teries and  a  loud  hum  in  the  jugular  veins.  The 
carotids  pulsate  violently  and  often  a  thrill  may 
be  felt  over  them. 

Remember  that  a  positive  diagnosis  can  be  made 
only  by  examination  of  the  blood,  which  will  pre- 
sent the  following  characteristics:  clotting  less 
readily  than  normal;  a  great  reduction  in  the  num- 
ber of  the  red  cells;  the  presence  of  pathological 
forms  of  cells,  as  poikilocytes  and  megolocytes;  the 
hemoglobin  percentage  is  reduced,  but  the  color 
index  is  high.  There  is  no  leucocytosis,  but  in  some 
cases  there  is  an  increase  in  the  number  of  lympho- 
cytes. 

Treatment. 

The  following  gives  a  concise,  but  complete,  out- 
line of  the  treatment:  first,  a  diagnosis;  second, 
rest  in  bed;  third,  plenty  of  fresh  air,  and,  if  possi- 
ble, in  the  open  air;  fourth,  all  the  good  food  the 
patient  can  take;  fifth,  arsenic. 

Fowler's  solution  is  probably  the  best  form  in 
which  to  administer  the  arsenic.    Give  it  in  increas- 


108  DISEASES    OP   THE    BLOOD. 

ing  doses,  beginning  with  3  minims  three  times 
daily  and  increase  1  minim  each  week  until  15  or  20 
minims  are  given  at  a  dose,  or  until  toleration  is 
reached. 

Normal  saline  solution  by  hypodermoclycis  or 
into  the  vein  is  beneficial  if  given  rather  frequently. 
It  checks  the  destruction  of  red  cells  by  the  blood 
serum. 

Mouth  should  be  cleansed  thoroughly  daily  with 
some  antiseptic  mouth  wash.  Iron  appears  to  be  of 
benefit  in  a  few  cases. 

Salol  is  given  by  some  on  the  theory  that  the 
disease  is  caused  by  absorption  of  toxins  from  the 
bowels. 

Arsenic  may  be  given  hypodermatically  as  sodium 
arsenate  gr.  Yeo,  or  atoxyl  (meta-arsenic  acid  anilid), 
using  6  minims  of  15-percent  or  20-percent  solu- 
tion. Warm  the  solution,  to  be  sure  of  complete 
solution  of  the  atoxyl.  The  dose  is  increased  6  min- 
ims daily  until  5  grains  of  atoxyl  are  given  and  con- 
tinued for  four  weeks,  then  reducing  the  injections 
to  two  a  week,  then  one  a  week,  then  intermit  the 
treatment  for  from  six  to  eight  weeks. 

Remember  that  serious  results  have  followed  the 
hypodermatic  use  of  arsenic.  Fowler's  solution,  di- 
luted with  2  parts  of  water,  may  be  used. 

Leukemia. 

Remember  that  the  onset  is  insidious,  and  the 
patient  may  seek  advice  for  a  progressive  enlarge- 


LEUKEMIA.  109 

ment  of  the  abdomen,  enlarged  glands,  or  for  palpi- 
tation and  dyspepsia,  or  for  severe  epistaxis. 

Remember  that  hemorrhage  is  exceedingly  com- 
mon, and  a  fatal  hematemesis  may  be  the  first 
symptom. 

In  the  splenomedullary  form  the  enlargement  of 
the  spleen  is  pronounced,  extending  downward  and 
to  the  right.  Its  notched,  sharp  border  usually 
identifies  the  tumor  as  splenic.  Splenic  friction  can 
often  be  heard  and  felt  over  the  tumor,  and  the 
enlarged  spleen  may  lift  the  heart  to  the  fourth 
costal  space  and  cause  dyspnea  from  its  size.  Some- 
times tenderness  over  the  sternum  and  the  long 
bones  can  be  elicited. 

Remember  that  there  are  four  cardinal  findings: 

1.  Enlargement  of  lymph  glands,  spleen,  and 
tonsils. 

2.  Hemorrhage.  This  is  the  most  characteristic 
and  frequent.  It  may  occur  into  the  skin,  retina, 
from  mucous  membranes,  or  into  viscera,  as  spleen 
or  brain. 

3.  Necrosis,  occurring  in  the  infiltrated  foci  of 
the  mouth.    This  condition  is  very  suggestive. 

4.  Lymphemia.  This  is  the  deciding  factor,  and 
no  positive  diagnosis  can  be  made  without  blood 
examination.  The  lymphocytes  are  greatly  in- 
creased, and  may  constitute  from  92  percent  to  98 
percent  of  the  leucocytes.  The  ratio  between  the 
red  and  white  cells  changes,  and  may  be  as  1:2 
or  1:1. 


110  diseases  of  the  blood. 

Teeatment. 

A  good  diet,  fresh  air,  rest,  and  abstaining  from 
mental  worry  are  the  important  general  conditions. 

Quinin  should  be  given  in  cases  with  a  malarial 
history. 

Phosphorus  is  given  by  some;  best  given  in  pill. 

Arsenic  is  the  best  agent  at  our  command  to  com- 
bat this  condition.  It  must  be  given  in  increasing 
doses  and  in  large  amounts.  Fowler's  solution  is 
the  form  mos-t  often  used.  Begin  with  5  drops  three 
times  daily  and  increase  1  drop  daily  until  40  or  50 
drops  are  taken.  If  slight  diarrhea  is  caused  by 
the  arsenic,  give  paregoric  with  it  and  occasionally 
a  slight  purgative  to  prevent  accumulation. 

Arsenious  acid  may  be  used,  but  should  always 
be  combined  with  black  pepper,  so  that  absorption 
will  be  hastened.  The  drug  may  be  used  hypoder- 
matically,  as  in  pernicious  anemia.  X-ray  is  often 
used,  and  in  a  few  cases  with  apparent  benefit. 
When  it  is  used  it  should  be  employed  cautiously, 
as  deaths  have  occurred  suddenly,  with  the  appear- 
ance of  toxemia  from  cell  destruction. 

Pseudoleukemia  (Hodgkin's  Disease). 

Remember  that  chronic  tonsillitis  of  several 
months'  standing  may  precede  Hodgkin's  disease. 
In  all  cases  of  enlargement  of  cervical  glands  the 
teeth  should  be  thoroughly  examined;  this  is  espe- 
cially true  in  the  young. 

Remember  that  anemia  is  not,  as  a  rule,  severe, 


PSEUDOLEUKEMIA.  Ill 

and  occurs  late  in  the  disease,  and  that  an  exam- 
ination of  the  blood  usually  does  not  show  any  dis- 
proportion of  cells. 

Remember  that  the  temperature  curve,  if  fever 
exists,  is  rather  suggestive  of  a  toxemia  because  of 
its  irregularity,  and  is  often  accompanied  by  chills 
and  sweats. 

Remember  that  the  enlargement  of  the  axillary 
and  inguinal  glands  strongly  indicates  the  condition, 
but  unfortunately  does  not  occur  early.  Pressure 
symptoms  may  be  caused  by  the  enlarged  glands, 
the  axillary  causing  pain  and  swelling  in  the  hands 
and  arms,  and  the  inguinal  great  pain  and  swelling 
of  the  feet. 

Remember  that  bronzing  of  the  skin  may  occur 
and  an  obstinate  pruritus.  Eecurring  boils  are 
frequent. 

Remember  that  tuberculous  glands  of  the  neck 
very  closely  simulate  this  condition. 

1.  The  differentiation  should  be  made  by  remov- 
ing one  of  the  glands  under  cocaine  and  examine 
it.  The  histologic  changes  in  the  gland  in  tuber- 
culous infection  are  distinct  and  the  bacilli  may  be 
found. 

2.  Tuberculin  should  be  used  if  the  patient  has 
no  fever.  In  early  tubercular  adenitis  the  reaction 
is  prompt.  It  should  be  used  continuously,  and  a 
daily  record  kept  of  the  temperature. 

3.  Periadenitis  is  very  common  in  tuberculous 
glands,  and  the  skin  becomes   adherent   and   the 


112  DISEASES   OF    THE    BLOOD. 

glands  are  not  movable.     Eventually  some  of  the 
glands  break  down  and  discharge. 

Remember  that  the  blood  count  will  decide  for  or 
against  leukemia. 

Teeatment. 

Operation  for  the  removal  of  the  enlarged  glands 
should  be  advised  when  the  superficial  glands  of 
one  side  of  the  neck  are  involved.  Even  when  the 
glands  of  both  sides  are  involved,  if  there  are  no 
mediastinal  glands  involved,  operation  is  advisable. 

X-ray  in  selected  cases  does  some  good.  The 
glands  may  be  reduced  in  size,  but  it  is  questionable 
whether  a  cure  is  effected. 

Morphin  should  be  used  to  relieve  pressure  pains. 

Tonics,  as  quinin,  iron,  and  codliver  oil,  should 
be  used. 

Arsenic  in  the  form  of  Fowler's  solution  gives 
the  best  results.  It  should  be  given  in  increasing 
doses,  beginning  with  nx  iij-Tii  v,  until  the  point  of 
toleration  is  reached. 

lodin,  locally  to  the  glands,  appears  to  be  harmful. 

Injection  into  the  glands  is  not  beneficial. 

Hypodermatic  injections  of  sodium  cocodylate 
may  be  used  instead  of  arsenic  when  it  irritates 
the  bowel.    May  be  combined  as  follows: 

IJ     Sodii  cocodylatis    gr.  xxv 

Cocainse  hydrochloridi   gr.  ss 

Sodii   eliloridi    gr.  j 

Aquae     destillatse     q.  s.  ad  §  j 

Misce  et  fiat  solutio. 

Sig. :   Inject  15  to  30  minims   daily. 


PURPURA.  113 

Purpura, 

Remember  that  this  may  occur  as  a  symptom  in 
various  conditions,  as  in  many  infectious  diseases 
— such  as  scarlatina,  sepsis,  measles,  variola,  etc.; 
or  it  may  be  of  a  toxic  nature — as  in  nephritis,  cho- 
lemia,  or  in  the  use  of  quinin,  mercury,  etc.  Often 
it  occurs  in  the  aged  in  malignant  tumors,  leukemia, 
pseudoleukemia,  and  pernicious  anemia. 

Remember  that  the  coagulating  time  of  the  blood 
is  greatly  lengthened.  The  eruption  is  usually 
macular,  but  may  be  papular  or  urticarious. 

Remember  that  it  seldom  occurs  on  the  face,  but 
usually  confined  to  the  extensor  areas  of  the  ex- 
tremities, especially  the  legs. 

Remember  that  in  purpura  rheumatica  the  joints 
are  involved.  In  most  cases  tonsillitis,  with  fever, 
muscular  pains,  and  colic  are  initiatory  symptoms. 
Sloughing  of  the  tonsil  has  occurred.  The  joints 
most  commonly  involved  are  knees,  ankles,  or 
elbows. 

Remember  that  the  purpura  may  precede  or  fol- 
low the  joint  symptoms,  and  various  forms  of  the 
eruption  occur,  as  macular,  urticarious,  or  erythem- 
atous. 

Remember  that  there  is  a  great  tendency  to 
hemorrhage  from  mucous  surfaces,  as  nose,  mouth, 
alimentary  tract,  or  vagina.  These  hemorrhages 
may  be  serious  and  even  fatal.  - 

The  purpuric  spots  in  the  skin  do  not  disappear 


114  DISEASES   OF   THE    BLOOD. 

on  pressure,  and  the  best  way  to  observe  this  is 
by  pressing  over  the  spot  with  a  glass  slide. 

Treatment. 

The  diet  should  be  carefully  watched.  All  acids 
and  acid  fruits,  crabs,  lobsters,  and  egg  albumen 
(Wright's  decalcifying  agents)  should  be  avoided. 

Cathartics  should  be  used  to  keep  the  bowels  mod- 
erately free. 

Calcium  lactate,  or  chlorid  gr.  x-gr.  xxx,  should 
be  given,  so  that  the  coagulating  time  of  the  blood 
may  be  decreased. 

IJ     Calcii  lactatis gr.  xx 

Misce  et  fiat  charta  No.  I.    Dentur  tales  doses  No.  XII. 
(Waxed  paper.) 
Sig. :  Powder  four  times  daily. 

Or: 

IJ     Sodii   sulphocarbolatis    3  iij 

Styptieini    (Merck)    gr.  xv 

Aquse  mentlise  piperitse   §  ii j 

Syrupi    simplicis    3  j 

Aquse     3  ij 

Misce  et  fiat  solutio. 

Sig.:  Tablespoonful  every  four  hours. 

In  rheumatic  forms  the  antirheumatic  remedies 
must  be  administered. 

IJ,     Potassii  iodid    9  ij 

Sodii  salicylatis    3  ss 

Syrupi    simplicis    3  iv 

Aquae    q.  s.  ad  5  ij 

Misce. 

Sig. :    Dessertspoonful  every  four  hours. 


PURPURA.  115 

Where  a  good  general  tonic  is  needed,  the  follow- 
ing is  good: 

IJ     Arseni  trioxidi    gr.  j 

Quininae  muriatiei    3  ivs3 

Ferri  sulphatis  exsiccati o  j 

Extract!  nucis  vomicae   gr.  x 

Misce  et  fiant  pilulse  No.  LX. 

Sig. :  Pill  after  each  meal. 

Gelatin  may  be  used,  injecting  1^  ounce  of  a 
10-percent  solution  into  the  gluteal  region  to  check 
hemorrhage. 


CHAPTER  Vni. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

Addison's  Disease. 

Remember  that  tlie  onset  is  insidious,  the  patient 
gradually  losing  strength  and  energy.  Gastric  dis- 
turbances finally  cause  him  to  seek  relief. 

Remember  that,  while  pigmentation  is  an  im- 
portant sign,  it  is  variable,  both  as  to  the  time  of 
its  appearance  and  in  its  degree.  Usually  follow- 
ing the  constitutional  symptoms,  it  may  precede 
them  or  it  may  not  occur  until  shortly  before  the 
fatal  termination.  The  extent  of  pigmentation  is 
variable,  and  may  be  universal,  but  it  is  usually 
partial.  It  is  usually  seen  first  on  the  face,  neck, 
and  back  of  the  hands  and  fingers.  The  shade  of 
color  varies  from  lemon-yellow  to  dark-brown  or 
black;  usually  darker  on  exposed  parts  and  natur- 
ally pigmented  portions. 

Remember  that  pigmentation  is  not  pathogno- 
monic of  Addison's  disease.  The  following  must  be 
excluded:  1,  abdominal  growths,  as  tubercle,  cancer, 
or  lymphoma;  2,  uterine  disease  and  pregnancy;  3, 
hypertrophic  cirrhosis  and  diabetes;  4,  melanotic 
cancer  and  exophthalmic  goiter;  5,  pernicious  ane- 
mia and  prolonged  use  of  arsenic. 

The  occurrence  of  fainting  fits,  nausea,  gastric 
irritability,  and  asthenia  are  stronger  indications 
of  Addison's  disease. 

116 


Addison's  disease.  117 

Remember  that  asthenia  is  probably  the  most  fre- 
quent and  important  symptom.  Easily  tired  at  first, 
the  patient  finally  becomes  unable  for  any  exertion 
of  either  mind  or  body. 

Remember  that  there  is  no  emaciation  accom- 
panying the  muscular  feebleness.  There  may  be  ex- 
treme degree  of  muscular  prostration,  while  the 
muscles  feel  firm  and  hard,  with  no  emaciation,  and 
therein  lies  the  distinctive  quality  of  asthenia  in 
Addison's  disease.  This  loss  of  muscular  power 
extends  to  the  cardiac  muscle,  as  is  shown  by  the 
small,  extremely  soft,  and  compressible  pulse. 

Remember  that,  as  a  large  percentage  of  Addi- 
son's disease  is  due  to  tubercular  degeneration  of 
the  glands,  in  doubtful  cases  the  tuberculin  test  may 
be  used. 

Treatment. 

Rest  in  bed  is  imperative  because  of  the  exhaus- 
tion and  danger  of  fatal  syncope. 

Diet  must  be  nutritious  and  liberal. 

Tonics  are  indicated.  Arsenic  and  strychnin  are 
best. 

For  the  nausea  and  vomiting,  creosote,  phenol, 
ice,  and  hydrocyanic  acid  should  be  given. 

Diarrhea  is  best  controlled  by  large  doses  of  bis- 
muth. 

For  vomiting  and  diarrhea  the  following  is  good; 

IJ     Bismuthi  subnitratis   3  iv 

Creosoti    ( Beechwood )     TTt  v 

Aquae  menthse  piperitae §  iij 

Misce. 

Sig. :  Teaspoonful  every  two  or  three  hours.   Shake  well. 


118  DISEASES   OF   THE   DUCTLESS   GLANDS. 

Organotherapy  gives  good  results  in  many  cases; 
some  are  apparently  cured.  The  medullary  portion 
of  the  suprarenal  gland  is  the  part  used.  The  raw 
gland,  partially  cooked,  or  the  glycerin  extract  may 
be  used. 

IJ     Suprarenal  gland  desiccated   (U.  S. 

P.)     3ij 

Extract!  nucis  vomicae   gr.  iij 

Misce  et  fiant  capsulse  No.  XXIV. 

Sig. :   1  or  2  capsules  three  times  daily. 

Solution  of  adrenalin  chlorid  may  be  used  hypo- 
dermatically — a  dram  of  1:1000  solution  injected 
every  other  day. 

Exophthalmic  Goiter. 

Most  common  in  women  between  puberty  and  the 
menopause. 

Remember  that  there  are  four  cardinal  symptoms 
that  render  a  diagnosis  positive  when  present,  and  a 
positive  diagnosis  is  impossible  unless  some  of  them 
are  found.  They  are:  goiter,  exophthalmos,  tachy- 
cardia, and  tremor. 

The  goiter,  as  a  rule,  is  small  and  the  right  side 
of  the  gland  is  more  prominent.  The  tumor  is  soft 
and  uniform,  but  occasionally  may  be  irregular  and 
contain  rounded  or  nodular  masses  that  are  hard. 
Pulsations  can  usually  be  seen  in  the  gland  and  a 
murmur  heard  over  it.  On  palpation  a  systolic 
thrill  may  be  felt.  The  goiter  rarely  produces 
pressure  symptoms,  and  it  varies  in  size  at  different 
times. 


EXOPHTHALMIC    GOITEK.  119 

Remember  that  exophthalmos  is  present  and  often 
early.  It  may  be  unilateral.  The  amount  of  pro- 
trusion varies,  and  this  protrusion  produces  the  fol- 
lowing signs: 

1.  Grafe's  Sign.  The  upper  lids  lagging  behind 
in  the  downward  movement  of  the  eyeballs,  and 
the  scleras  become  visible  between  them  and  the 
cornea. 

2.  Stellwag's  Sign.  The  widening  of  the  palpe- 
bral fissure.  This  retraction  of  the  upper  lids 
causes  a  white  ring  of  sclera  to  be  seen  all  around 
the  iris. 

3.  Diminished  frequency  of  winking. 

4.  Mobius'  Sign.  The  inability  to  converge  for 
near-by  objects.  An  attempt  causes  a  sense  of 
strain,  but  no  double  vision.  This  sign  is  not  al- 
ways present. 

5.  Joifroy's  Sign.  The  head  is  bowed  forward 
and  the  patient  asked  to  look  up  without  changing 
the  posture.  The  forehead  is  not  wrinkled,  as  oc- 
curs in  health. 

Tachycardia  is  not  only  prominent,  but  one  of  the 
most  constant  signs.  The  rate  of  the  pulse  may  be 
very  high,  but  there  is  no  irregularity,  except  to- 
ward the  close. 

Remember  that  the  area  of  cardiac  pulsation  is 
increased  and  the  action  is  heaving  and  forcible. 
The  large  arteries  of  the  neck  throb  and  a  capillary 
pulse  is  readily  seen.  Frequently  a  pulse  can  be  seen 
in  the  veins  of  the  hands. 


120  DISEASES   OF   THE  DUCTLESS    GLA]!^DS. 

Remember  that  the  tremor  is  most  always  found, 
and  may  be  the  chief  trouble  of  complaint  by  the 
patient.  It  varies  in  degree,  and  may  be  discovered 
by  the  physician  only  after  careful  observation. 
The  tremors  usually  run  from  eight  to  ten  per  sec- 
ond, and  may  be  best  observed  by  the  patient 
standing,  hands  and  fingers  extended,  and  a  piece 
of  paper  laid  across  the  back  of  the  fingers.  The 
tremor  is  made  worse  by  excitement  and  worry. 

There  are  some  signs  that  are  of  secondary  im- 
portance in  making  a  diagnosis.  The  most  promi- 
nent are  the  following: 

1.  Emaciation  is  the  most  constant.  The  loss  of 
strength  is  dependent  upon  the  emaciation. 

2.  Sweating  is  frequent  and  often  a  troublesome 
symptom.  The  falling  of  the  hair  is  due  to  its  dis- 
turbed nutrition,  A  dry  cough  is  frequently  ob- 
served, due  to  pressure  upon  the  trachea. 

3.  Edema  of  the  feet  may  occur,  and  is  due  to  the 
cardiac  weakness. 

4.  A  change  in  the  mental  condition  will  often  be 
the  earliest  sign.  The  patient  becomes  irritable, 
excitable,  emotional,  fidgety,  and  restless;  is  unable 
to  concentrate  his  mind  and  longs  for  continuous 
changes. 

Treatment. 

Rest,  free  from  worry  and  anxiety,  is  imperative, 
and  in  severe  cases  it  is  best  to  confine  the  patient 
to  bed.     The  quietude  of  a  country  place,  where 


EXOPHTHALMIC    GOITER.  121 

there  is  plenty  of  good,  fresh  air  and  sunshine,  is 
the  best  place. 

Diet  must  be  abundant  and  mixed.  It  is  better 
to  somewhat  limit  the  amount  of  meat,  but  plenty 
of  proteids  must  be  given  because  of  the  large 
amount  of  nitrogen  eliminated.  Stimulants — as 
coffee,  tea,  alcohol,  chocolate,  and  condiments — 
must  be  prohibited. 

Hydrotherapy  often  gives  good  results.  The 
baths  may  be  given  at  home.  The  only  thing  to 
keep  in  mind  is  to  avoid  all  forms  of  stimulation,  as 
cold  douche  along  the  spine  or  hot  pack,  until  per- 
spiration begins.  In  all  forms  the  bath  should  be 
sedative  and  cold  kept  to  the  head. 

Electrotherapy  is  recommended  by  some.  Gal- 
vanism is  the  form  used.  The  positive  pole  is  placed 
under  the  angle  of  the  lower  jaw  with  moderate 
pressure.  The  negative  electrode  is  placed  on  the 
neck  at  the  height  of  the  lowest  cervical  vertebra. 
The  strength  of  the  current,  which  is  gradually  in- 
creased and  then  gradually  decreased,  is  applied 
for  two  to  three  minutes.  Both  sides  of  the  neck 
should  be  treated  in  this  way. 

Medication.  If  chlorosis  or  anemia  be  present, 
iron  and  arsenic  should  be  used. 

For  marked  nervous  symptoms  sodium  or  stron- 
tium bromid  should  be  exhibited.  Or  camphor 
monobromate  may  be  tried,  as: 

IJ     Camphorse  monobromatae    gr.  v-gr.  x 

Sacchari  lactis    gr.  ii j-gr.  v 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  pulveres  No.  XX. 
Sig. :    Powder  three  times  daily. 


122  DISEASES    OF    THE    DUCTLESS    GLANDS. 

Forcheimer's  metliod  gives  excellent  results  and 
consists  in  giving  quinin  hydrbbromate  gr,  v  in  gela- 
tin-coated pill  four  times  daily,  and,  if  no  improve- 
ment within  forty-eight  hours,  he  adds  ergotin  gr.  j. 
He  claims  a  cure  in  from  70  to  90  percent  of  cases. 
The  time  of  treatment  varies  from  four  months  to 
three  years.  Cromium  sulphate  gr.  v  three  or  four 
times  daily  often  gives  surprisingly  good  results. 

Beebe  and  Rogers  have  prepared  a  serum  by  in- 
jecting animals  with  pathological  glands.  They 
claim  remarkably  favorable  results,  but  it  must  be 
used  early.  After  the  profound  anatomical  changes 
occur  in  other  organs  it  appears  to  be  less  potent. 

Sodium  phosphate  in  %  to  2  drams  daily  acts 
beneficially,  especially  upon  the  nervousness. 

Ortner  highly  recommends  dilute  sulphuric  acid, 
10  drops  three  times  daily,  for  the  vasomotor  dis- 
turbances so  often  occurring. 

Tincture  of  convallaria  and  belladonna  in  full 
doses  will  often  quiet  the  heart  and  reduce  the  pulse 
rate. 

lodin  in  any  form,  locally  or  internally,  should  be 
studiously  avoided  in  malignant  goiter.    Theoretic- - 
ally,  the  same  advice  applies  to  thyroid  extract. 

Surgery,  while  responsible  for  some  sudden 
deaths  from  acute  cardiac  dilatation,  does  in  some 
cases  offer  relief,  or  even  a  cure. 

Milk  from  thyroidectomized  goats  has  given  re- 
sults in  a  few  cases.  Chemists  have  produced  a  sub- 
stance from  the  milk  called  rodagen,  and  is  said 


EXOPHTHALMIC    GOITEE MYXEDEMA.  123 

to  contain  50  percent  of  the  active  constituent  of 
the  milk  and  50  percent  milk  sugar.  From  1  to  3 
drams  are  given  daily.  Patients  sleep  better  and 
are  less  nervous  while  taking  it. 

Merck  prepares  a  serum  from  thyroidless  sheep 
that  is  said  to  be  useful,  but  the  expense  of  both 
of  these  preparations  limits  their  use. 

Myxedema. 

There  are  two  forms,  and  the  division  relates  only 
to  age,  as  both  are  caused  by  the  atrophy  of  the 
thyroid.  The  forms  are  cretinism,  occurring  in 
children,  and  myxedema  of  the  adult. 

Remember  that  it  is  difficult  to  diagnose  cretin- 
ism prior  to  the  first  year. 

Remember  that  a  child  that  stops  growing,  and 
there  is  lack  of  proportion  between  the  various 
parts  of  the  body,  so  that  there  is  a  plump  head, 
a  short  and  deformed  body,  and  thick,  "pudgy" 
arms  and  legs,  should  strongly  suggest  cretinism. 
The  large  head  is  flat  at  the  top,  narrow  in  front, 
and  broad  behind.  The  face  is  broad  and  expres- 
sionless. The  forehead  is  low  and  broad.  The  eyes 
are  dull  and  appear  to  be  half  closed,  caused  by  the 
swollen  lids,  and  are  wide  apart.  The  nose  is  stub- 
by, depressed  at  the  root,  nostrils  widely  opened, 
and  the  alse  thickened.  The  ears  are  thickened. 
The  lips  are  thick  and  protruding.  The  tongue  is 
swollen  and  protrudes. 

Remember  that  the  skin  is  dry  and  harsh,  and  ap- 


124  DISEASES   OF    THE    DUCTLESS    GLANDS. 

parently  dropsical,  but  will  not  pit  in  cretinism, 
while  in  rickets  there  are  the  sweating  head,  cranio- 
tabes  and  swollen,  tender  joints. 

Remember  that  mental  dullness,  backwardness 
about  learning  to  talk  and  walk,  and  the  disturbance 
of  the  special  sense  of  taste  and  hearing  character- 
ize cretinism. 

Myxedema  occurs  more  frequently  in  women  and 
between  the  fifteenth  and  forty-fifth  years — ^the 
child-bearing  period. 

Remember  that  the  onset  is  insidious,  but  languor, 
undue  sensitiveness  to  cold,  with  slight  auditory  and 
visual  hallucinations,  and  swollen  eyelids  mark  the 
onset  of  athyria. 

Remember  that  there  are  some  characteristic 
signs  that  are  found  in  no  other  conditions,  and  the 
following  are  the  most  prominent: 

1.  Dense,  inelastic  swelling  of  the  subcutaneoug 
tissues,  which  do  not  pit  upon  pressure.  It  is 
most  abundant  where  subcutaneous  tissues  are  lax, 
and  thus  gives  a  peculiar  appearance  to  the  face  and 
hands. 

2.  A  change  in  the  facial  expression,  due  to  the 
obliteration  of  the  lines  of  expression — the  swollen 
eyelids,  the  transverse  wrinkles  of  the  forehead,  the 
thickened  and  enlarged  nose,  and  swollen  lip. 

3.  The  swollen  and  shapeless  hands  and  feet. 

4.  Increase  of  size  and  body  weight. 

5.  Subnormal  temperature. 

6.  Mental  dullness  and  muscular  weakness. 


myxedema.  125 

Treatment. 

There  is  nothing  else  in  our  therapeutics  that  is 
so  satisfactory  as  the  treatment  of  this  condition. 

The  thyroid  gland,  or  extract  made  from  it,  may  be 
given.  It  is  better  to  give  the  extract  put  up  in 
tablets.  The  dose  at  the  beginning  should  be  small 
and  cautiously  increased.  Whenever  the  following 
symptoms  appear,  the  treatment  must  be  stopped 
for  a  few  days:  these  are  palpitation,  faintness, 
dyspnea,  anorexia,  nausea,  vomiting,  nervousness, 
tremor,  and  sense  of  fear.  It  is  better  to  begin 
with  from  1  to  2  grains  and  gradually  increase  until 
from  15  to  30  grains  are  taken. 

I^     Tablet  thyroidin   ( Merck )    aa  gr.  i j 

No.  C. 

Sig. :  Tablet  three  times  daily,  gradually  increasing    until 
four  are  taken. 

Or: 

IJ     Thyroidin   gr.  xxx-gr.  xl 

Arseni  trioxidi    gr.  j 

Extracti  nucis  vomicae   gr.  ii j 

Misce  et  fiant  pilulae  No.  LX. 

Sig.:    Pill  three  times   dailyj   gradually  increasing    until 
three  or  four  are  taken.    Interrupt  treatment  occasionally. 

In  infantile  form  or  cretinism  Forcheimer's  rule 
of  dosage  is  good,  and  is  as  follows:  the  adult  dose 
is  taken  at  5  grains  and  the  dose  for  an  infant  is 
obtained  by  taking  one-twentieth  of  the  fraction  ob- 
tained by  dividing  the  age  in  months  by  twelve. 
Thus  for  a  child  four  months  old,  Vzo  of  %2  of  5  equal 
H2;  hence  the  dose  would  be  gr.  %2  for  a  child  four 


126  DISEASES    OF   THE    DUCTLESS    GLANDS. 

months  old.  He  cautions  against  even  the  small 
dose  and  advises  to  begin  by  giving  it  once  a  day, 
then  twice,  and  finally  thrice.  The  untoward  symp- 
toms in  children  are  restlessness,  poor  sleep,  loss 
of  appetite,  and  irritability.  It  should  not  be 
pushed  until  the  graver  symptoms  of  rapid  pulse, 
vomiting,  or  collapse  occur. 


CHAPTER  IX. 

DISEASES  OF  THE  VASCULAR  SYSTEM. 

Pericarditis. 

Remember  that  many  of  the  idiopathic  varieties 
are  tubercular  in  origin,  and  that  rheumatism  is 
the  most  frequent  cause  of  the  secondary  variety. 

Remember  that  the  acute  fibrinous  stage  may  or 
may  not  be  followed  by  an  effusion  into  the  peri- 
cardium. 

Remember  that  in  the  early,  or  fibrinous,  stage 
auscultation  furnishes  the  only  conclusive  evidence, 
and  that  the  friction  sound  thus  heard  possesses  the 
following  characteristics : 

1.  It  is  double,  and  corresponds  to  the  systole  and 
diastole  of  the  heart. 

2.  It  is  a  to-and-fro  murmur,  and  outlasts  the  first 
and  second  sounds  of  the  heart. 

3.  The  sound  has  a  peculiar  rubbing  or  grating 
quality,  or  it  may  be  comiDared  to  creaking  of  new 
leather. 

4.  It  is  best  heard  over  the  right  ventricle — the 
fourth  and  fifth  interspace,  at  the  left  sternal  mar- 
gin— and  appears  to  be  superficial  or  close  to  the 
stethoscope. 

5.  Variability.  It  may  be  heard  at  one  time  and 
not  at  another. 

6.  The  murmur  may  be  intensified  by  pressure 
upon  the  stethoscope. 

127 


128  DISEASES   OF   THE    VASCULAE    SYSTEM. 

7.  There  are  no  definite  lines  of  transmission,  as 
in  endocardial  murmurs,  and  is  usually  heard  over 
a  limited  area  at  the  border  of  the  sternum. 

Remember  that  when  effusion  occurs,  the  friction 
sound  disappears  over  the  body  of  the  heart,  but 
may  be  heard  at  the  base.  There  is  an  accentuation 
of  the  second  pulmonic  sound,  while  the  first  is  ob- 
scure. The  cardiac  action  is  rapid  and  frequently 
arhythmic. 

Remember  that  in  well-developed  cases  of  effu- 
sion the  symptoms  may  be  grouped  as  constitu- 
tional and  local. 

Constitutional  Signs.  Fever,  restlessness,  dysp- 
nea, anorexia,  pallor,  insomnia,  melancholia,  with 
suicidal  tendencies. 

Pain  varies  from  sharp,  lancinating  to  dull,  ach- 
ing, and  is  made  worse  by  pressure  over  the  area 
with  the  stethoscope. 

The  dyspnea  varies  with  the  amount  of  effusion — 
from  breathlessness,  when  the  patient  prefers  to  lie 
on  the  left  side ;  to  air  hunger  and  extreme  dyspnea, 
when  he  is  obliged  to  be  propped  up  in  bed. 

The  pulse  is  rapid,  small,  and  may  be  arhythmic. 
It  may  be  obliterated  during  inspiration  in  large  ef- 
fusion— pulsus  paridoxicus.  It  may  be  smaller  in 
the  left  than  right  radial  artery. 

Physical  Signs.  Inspection  shows  precordial 
prominence,  and  widening  and  bulging  of  the  lower 
intercostal  spaces.  Palpation  shows  feeble  cardiac 
impulse. 


PERICARDITIS.  129 

First  rib  sign  is  found  where  there  is  a  large 
amount  of  effusion.  It  produces  an  elevation  of  the 
clavicle,  with  a  bulging  of  the  left  retro  clavicular 
space,  so  that  the  first  rib  can  be  easily  palpated  to 
the  sternum. 

Percussion  yields  the  most  important  sign,  but 
a  certain  amount  of  effusion  is  necessary  before  it 
can  be  detected. 

Botch's  Sign.  With  a  normal  or  dilated  heart 
the  vertical  border  of  the  heart  forms  a  right  angle 
with  the  upper  transverse  hepatic  dullness.  When 
elfusion  occurs,  this  angle  is  replaced  by  a  more  or 
less  curved  line. 

Triangle  Sign.  When  effusion  takes  place  into 
the  pericardium,  it  collects  in  the  most  dependent 
j)ortion  of  the  sac,  and  as  it  increases  it  widens  the 
area  of  dullness.  This  forms  a  triangle,  with  the 
base  downward  and  apex  up  in  the  precordial 
region.  The  right  leg  of  the  triangular  dullness 
may  reach  to  or  beyond  the  right  border  of  the 
sternum,  while  the  left  leg  may  extend  to  the  left 
anterior  axillary  line. 

It  is  important  to  remember  that  cardiac  dullness, 
particularly  the  left  leg  of  the  triangle,  extends  be- 
yond the  apex  beat,  which  is  also  pulled  downward 
and  to  the  left. 

Remember  that  the  pressure  of  the  effusion  pro- 
duces symptoms  in  other  organs,  but  the  most  im- 
portant ones  are  dysphagia,  paralysis  of  the  vocal 
cords,  vomiting,  and  singultus. 


130  DISEASES    OF    THE    VASCULAR    SYSTEM. 

Remember  that,  in  differentiating  between  cardiac 
effusion  and  cardiac  dilatation,  an  undulatory  im- 
pulse seen  or  felt  in  two  or  more  interspaces;  dis- 
tinct, though  feeble,  heart  sounds,  valvular  in  char- 
acter, but  having  the  fetal  rhythm;  and  changes 
in  the  upper  border  of  dullness  by  postural  changes, 
are  strongly  suggestive  of  effusion. 

Remember  that  in  left-sided  pleural  effusion  the 
heart  is  displaced  to  the  right,  the  cardiac  impulse 
and  valvular  sounds  are  distinct,  and  the  area  of 
flatness  extends  around  the  base  of  the  chest. 

Treatment. 

Remember  that  rest  in  bed  is  imperative,  so  that 
the  work  of  the  heart  may  be  lessened. 

Diet  should  be  liquid  and  principally  milk.  If 
the  case  extends  over  a  period  of  two  weeks,  it  is 
better  then  to  add  to  the  diet,  so  that  the  nutrition 
of  the  cardiac  muscle  will  be  maintained. 

Medicinal.  If  the  pericarditis  is  of  rheumatic 
origin,  sodium  salicylate  is  indicated.  It  should  be 
given  with  potassium  bicarbonate.  Ice  bag  should 
be  applied  over  the  cardiac  region  to  quiet  the  heart. 
Morphin,  given  hypodermatically,  is  often  beneficial 
to  relieve  dyspnea.  Tincture  of  aconite  ttl  iij-trt  v 
m.ay  be  given  for  the  same  purpose.  Amorphous 
aconitin  gr.  %3o,  given  every  half  to  one  hour  to 
effect,  is  much  better.  Digitalis  is  the  best  aid  in 
this  as  in  other  cardiac  affections.  It  may  be  given 
combined  as  follows : 


PERICARDITIS.  131 


I^.     Potassii  acetatis   3  ij 

Spiritus  setheris  nitrosi    3  ij 

Tincturse   digitalis    5  j 

Aquae    mentlise    piperitae     ...  q.  s.  ad  §  ij 

Misce. 

Sig. :   Teaspoonful  every  four  hours. 


Or: 


R     Potassii  citratis    5  ij 

Infusi  digitalis  ( fresh  leaves )  .  .  .  .  3  ij 
Aquae  menthse  piperitae    ....  q.  s.  ad  §  vj 

Misce. 

Sig.:   Tablespoonful  every  four  hours. 


Or: 

R     Tineturae  digitalis, 

Tincturse  scillse    aa  3  ij 

Misce. 

Sig. :   20  to  30  drops  three  times  daily. 

If  constipation  exists,  mild  laxatives  should  be 
used.  Should  the  fluid  persist,  it  then  becomes  nec- 
essary to  tap  the  pericardium  and  draw  it  off. 

The  technic,  according  to  Curschmann,  is  as  fol- 
lows: The  place  chosen  is  the  fifth  intercostal 
space  in  the  left  mammary  line,  a  point  midway 
between  the  apex  beat  and  left  border  of  absolute 
dullness;  or  Bristow's  choice,  immediately  to  the 
left  of  the  sternum  in  the  fourth  or  fifth  space, 
which  latter  location  avoids  wounding  the  artery 
and  pleura.  The  skin  is  properly  cleansed  and  may 
be  anesthetized,  and  a  small  trocar  and  cannula 
pushed  through  the  chest  wall  and  pericardium. 
When  the  point  passes  through  the  pericardium, 
the  sense  of  resistance  ceases.    A  Potain  aspirator 


132  DISEASES    OF    THE    VASCULAR    SYSTEM. 

may  be  used.  The  fluid  sliould  be  allowed  to  flow 
out  very  slowly  and  the  patient  watched  carefully, 
as  sudden  death  sometimes  occurs.  After  the  fluid 
is  all  withdrawn,  a  collodion  dressing  is  applied. 
To  lessen  the  troublesome  adhesions  that  so  often 
occur  after  withdrawing  the  fluid,  it  is  well  to  give 
digitalis  at  intervals  until  recovery. 

Acute  Endocarditis. 

Remember  that  this  condition  is  most  always,  if 
not  always,  due  to  some  infectious  process,  and  that 
rheumatism,  chorea,  pneumonia,  and  scarlatina  are 
exceedingly  apt  to  produce  it. 

Remember  that  in  simple  endocarditis  two  things 
should  be  watched  for,  announcing  its  onset.  In  or- 
der of  importance,  they  are  pulse  rate  and  tempera- 
ture. The  rapid  pulse  may  be  irregular  and  palpi- 
tation be  complained  of. 

Remember  that  the  earliest  sign  that  ausculta- 
tion reveals  is  a  slight  roughening  of  the  "first 
sound."  Later  there  may  or  may  not  be  a  murmur 
— systolic,  or  diastolic  in  time. 

Remember  that  reduplication  and  accentuation  of 
the  pulmonic  second  sound  is  frequent. 

Remember  the  more  pronounced  general  symp- 
toms— as  irregular,  rapid,  feeble  pulse;  faintness, 
oppression,  pallor,  perspiration,  and  precordial  pain. 

Malignant  Endocarditis. 

Remember  that  the  history  of  the  case  is  all-im- 
portant in  the  diagnosis. 


MALIGIS^ANT    EOT)OCARDITTS.  133 

Remember  that  we  have  two  groups  of  symptoms 
— those  of  the  primary  disease  and  those  of  the 
endocarditis — and  the  clinical  picture  varies  ac- 
cording to  the  domination  of  the  one  or  the  other 
group.  To  the  first  group  belong  the  irregular 
fever,  sweating,  anemia,  delirium,  and  loss  of 
strength.  To  the  second  belong  the  air  hunger 
symptoms,  as  dyspnea,  orthopnea,  palpitation,  and 
irregular,  but  frequent,  cardiac  action. 

Remember  that  emboli  are  common,  and  the  signs 
vary  with  their  location. 

Remember  that  chills,  fever,  and  sweat  may  occur 
periodically  in  some  cases,  and  strongly  suggest 
malaria,  but  the  absence  from  the  blood  of  the 
malarial  parasite  is  conclusive. 

Treatment. 

Rest  in  bed,  free  from  worry,  in  all  infectious  dis- 
ease likely  to  be  complicated  by  endocarditis,  is  the 
best  prophylaxis  and  becomes  imperative  after  its 
onset.  • 

Cold  over  the  cardiac  area  or  a  mustard  plaster 
is  good  to  quiet  the  rapid  heart  action.  The  diet 
should  be  liquid  and  nutritious.  If  rheumatism  be 
the  cause,  salicylate  and  alkalies  should  be  given; 
this  is  extremely  important  in  children,  as  the  joint 
symptoms  are  so  mild.  With  rapid,  weak  heart, 
digitalis  should  be  used.  If  there  is  cardiac  irrita- 
tion manifested  by  tachycardia  and  pain  in  the  pre- 
cordial region,  it  is  well  to  combine  aconite  with 
it,  as: 


134  DISEASES    OF    THE    VASCULAR    SYSTEM. 

R     Tincturae  digitalis    3  iiias 

Tineturae    aconiti    3  iss 

Misce. 

Sig. :   15  drops  three  or  four  times  daily. 

Eicliorst  claims  to  have  cured  a  case  by  a  com- 
bined use  of  quinin  and  bichlorid  of  mercury,  as 
follows : 

IJ.     Quininae   hydrochloridi    gr.  Ixxv 

Hydrargyri  cliloridi  corrosivi   .....  gr.  ii  j 

Pulveris    glycyrrhizge    3  ss 

Extract!    gentianse     q.  s. 

Misce  et  fiat  massa.     Divide  in  pilulae  No.   XX, 

Sig.:   3  pills  daily  after  eating. 

Oollargol  (Crede)  is  claimed  by  Ortner  to  be  tbe 
best  remedy  in  all  cases  of  sepsis,  pyemia,  and  bac- 
teremia. If  tlie  ointment  be  used,  the  skin  over  the 
area  to  be  rubbed  is  cleansed  with  alcohol  and 
dried.  Then  45  grains  of  15-percent  unguenti  col- 
largoli  rubbed  in  carefully  until  the  skin  shows  a 
grayish-brown  tinge. 

Rectal  Use. 

IJ.     Collargoli     gr.  xv 

Aquse  destillatse    3  vj 

Sig.:  The  bowel  is  first  irrigated  with  a  cleansing  enema 
in  the  morning  and  half  of  the  above  amount  is  run  into 
the  rectum  slowly,  and  the  balance  is  given  in  the  evening. 

Potassium  iodid  is  recommended  to  stimulate  ab- 
sorption of  the  inflammatory  product  on  the  valves 
and  prevent  its  conversion  into  fibrous  tissue.  It 
should  not  be  given  until  subsidence  of  the  inflam- 
matory condition,  and  then  administered  cautiously 
and  alternated  with  digitalis. 


VALVULAR    DISEASE    OF    THE    HEAET.  135 

A  saturated  solution  may  be  used,  or  the  follow- 
ing: 

IJ     Potassii   iodidi    gr.  xs 

Potassii   bicarbonatis    3  ij 

Spiritus   anunonii  aromatici    o  ij 

Tincturae  cinchonae  compositse    3  v 

Aquse    q.  s.  ad  §  iv 

Misce. 

Sig. :    Tablespoonful    three   times    daily. 

Valvular  Disease  of  the  Heart. 

Aortic  Incompetency. 

Remember  that  this  is  the  lesion  of  the  athlete 
and  occurs  in  able-bodied,  vigorous  men. 

Remember  that,  etiologicall}^,  there  are  three 
groups: 

1.  Those  of  congenital  malformation. 

2.  Those  due  to  endocarditis. 

3.  Those  caused  by  arteriosclerosis. 

The  last  is  by  far  the  most  common,  and  is  usually 
associated  with  a  history  of  prolonged  muscular 
strain. 

Remember  that  the  earliest  signs  are  usually 
those  due  to  arterial  anemia,  as  headache,  dizziness, 
flashes  of  light,  and  a  feeling  of  faintness  on  sudden 
rising. 

Remember  that  pain  in  the  precordial  region  may 
be  severe,  and  is  often  transmitted  up  the  neck  and 
down  the  arm. 

Further  failure  of  compensation  jiroduces  dysp- 
nea, but  rarely  cyanosis,  hemoptysis,  and  edema  of 
the  feet. 


136  DISEASES    OF   THE   VASCULAR    SYSTEM. 

Remember  tliat  mental  disturbances  are  very  com- 
mon in  tliis  lesion,  such,  as  delirium,  hallucinations,, 
and  morbid  impulses,  with  suicidal  tendencies. 

Eemember  that  anasarca  is  rare,  while  sudden 
death  is  more  common  than  in  the  other  valvular 
lesions. 

Remember  the  value  of  examining  the  arteries 
in  this  condition.  The  following  signs  are  more  or 
less  distinctly  characteristic  of  aortic  incompe- 
tency : 

1.  The  visible  pulsations  in  the  peripheral  vessels. 

2.  The  pulsation  is  accompanied  by  a  character- 
istic jerking.  The  aorta  may  lift  the  epigastrium 
with  each  pulsation. 

3.  Corrigan  's,  or  water-hammer,  pulse.  The  pulse 
wave  strikes  the  finger  with  a  quick,  jerking  im- 
pulse and  immediately  collapses.  The  peculiarities 
of  the  pulse  may  be  emphasized  by  grasping  the 
arm  above  the  wrist  and  holding  it  up. 

4.  Retardation  of  the  pulse.  There  is  an  appre- 
ciable interval  between  the  heart  beat  and  the  radial 
pulse. 

5.  Capillary  pulse,  seen  in  the  finger  nails;  or,  by 
drawing  a  line  upon  the  forehead,  the  margins  of 
the  hyperemia  alternately  blush  and  pale. 

It  is  important  that  you  auscultate  over  the 
carotid  artery,  because  the  second  sound  can  be 
heard  here  when  absent  at  the  aortic  cartilage; 
when  the  second  sound  is  audible  over  the  carotid, 
it  indicates  the  regurgitation  is  small  in  amount, 
and  hence  a  favorable  prognostic  element. 


VALVULAR    DISEASE    OF   THE   HEART.  137 

Remember  tliat  the  murmur  heard  has  a  soft, 
blowing  quality,  and  is  loudest  at  midsternum,  oppo- 
site the  third  costal  cartilage,  or  along  the  left  bor- 
der of  the  sternum.  It  is  heard  during  ventricular 
diastole,  and  is  produced  by  back-flow  of  blood  from 
the  aorta. 

The  Austin  Flint  murmur  is  a  second  murmur 
limited  to  the  apex,  and  is  of  a  ''rumbling,  echoing" 
character.  It  is  presystolic  in  time  and  occurs  in 
the  latter  half  of  diastole.  It  is  often  associated 
with  a  palpable  thrill. 

Remember  that  this  is  the  lesion  associated  with 
massive  hypertrophy,  and  the  apex  beat  may  be 
seen  in  the  seventh  or  eighth  interspace  on  the 
anterior  axillary  line. 

Aortic  Stenosis. 

Remember  that  arterial  changes,  which  are  so 
prone  to  occur  in  old  men,  lay  the  foundation  for 
stenosis. 

Remember  that  no  symptoms  appear  until  a  break 
in  compensation  occurs,  when  the  earliest  are  those 
of  cerebral  anemia — viz.,  syncope,  dizziness,  head- 
ache. 

Remember  that,  while  the  high  degree  of  muscu- 
lar hypertrophy  is  present,  yet  the  apex  beat  may 
not  be  easily  seen  because  of  coexisting  pulmonary 
emphysema. 

Remember  that  a  marked,  systolic  thrill,  most  in- 
tense in  the  aortic  region,  is  very  characteristic  of 
this  lesion. 


138  DISEASES   OF   THE   VASCULAR    SYSTEM. 

Remember  that  the  murmur  is  a  harsh  systolic, 
and  loudest  over  the  second  right  costal  cartilage. 

Remember  that  the  murmur  is  transmitted  into 
the  carotids,  and  it  often  has  a  musical  quality. 

Remember  that  not  every  murmur  heard  in  this 
region  is  due  to  aortic  stenosis.  Calcareous  plates 
in  the  aorta  or  on  the  cusp  produce  a  very  similar 
sound.  Anemia  causes  hemic  murmurs  that  are 
often  best  heard  in  the  aortic  area,  but  this  soft 
bruit  is  very  different  from  the  loud,  harsh  murmur 
of  stenosis. 

Remember  that  in  both  the  sclerosis  and  the 
anemia  the  aortic  second  sound  is  heard,  and  in  the 
former  it  is  accentuated. 

Remember  that  the  pulse  is  small  and  slow — 
pulsus  tardus — and  is  somewhat  characteristic  of 
stenosis. 

Mitral  Incompetency. 

Remember  that  so  long  as  muscular  hypertrophy 
is  able  to  overcome  the  valvular  defect,  the  patient 
will  suffer  no  inconvenience  from  the  lesion,  except 
perhaps  a  little  shortness  of  breath  on  sudden  ex- 
ertion, as  running  up  a  flight  of  stairs. 

Symptoms  are  not  a  sign  of  the  beginning  of  the 
lesion,  but  of  the  beginning  of  inequality  between 
the  lesion  and  the  hypertrophy. 

Remember  that  this  is  the  lesion  which,  in  long- 
standing cases,  particularly  in  children,  produces 
clubbing  of  the  fingers. 


VALVULAR   DISEASE    OF   THE    HEART.  139 

Remember  that  attacks  of  bronchitis  and  hemo- 
ptysis are  quite  frequent,  due  to  the  pulmonic  con- 
gestion. 

Remember  that  we  have  persistent  cough,  with 
blood-stained  sputa,  containing  alveolar  cells  and 
pigment  granules. 

Remember  that  the  cardiac  "sleep  start"  is  a  dis- 
tressing symptom.  Just  as  the  patient  falls  asleep 
he  wakes,  gasping  for  breath  and  feeling  as  though 
the  heart  were  stopping. 

Remember  the  peculiarity  of  the  pulse.  It  is  ir- 
regular, with  no  two  beats  of  equal  force  or  volume, 
and  persists  even  though  compensation  be  re-estab- 
lished. 

Remember  that  the  apex  beat  will  be  found  dis- 
placed downward  and  to  the  left,  and  is  seen  in  the 
sixth  costal  space  to  the  left  of  the  nipple  line. 

Remember  that  the  murmur  is  systolic,  and  loud- 
est at  the  apex.  It  is  a  blowing  sound,  and  may 
entirely  replace  the  valvular  sound. 

Remember  that  this  murmur  may  be  heard  also 
in  the  axillary  space  and  beneath  the  angle  of  the 
scapula  posteriorly. 

Remember  the  peculiar  phenomenon  that  the  re- 
cumbent position  makes  it  plainer,  and  often  a  mur- 
mur can  be  heard  in  the  recumbent  posture  that  is 
inaudible  in  the  upright  position. 

Remember  that  percussion  shows  decided  lateral 
increase  of  the  heart,  due  to  hypertrophy. 

Remember  that  the  three  important  physical 
signs  of  mitral  regurgitation  are : 


140  DISEASES    OF    THE    VASCULAR    SYSTEM. 

1.  A  systolic  murmur,  loudest  at  the  apex  and 
propagated  to  the  axilla  and  heard  at  the  angle  of 
the  scapula. 

2.  Accentuation  of  the  second  pulmonic  sound. 

3.  Increase  in  the  transverse  diameter  of  cardiac 
dullness,  due  to  hypertrophy  of  both  ventricles. 

Mitral  Stenosis. 

Eemember  that  this  is  much  more  common  in 
females. 

Remember  that  this  is  the  only  valvular  lesion 
that  has  a  characteristic  thrill  on  palpation. 

Eemember  that  the  hypertrophy  is  all  in  the  right 
heart  and  increase  of  dullness  is  to  right  of  sternum. 

Eemember  that  the  thrill  is  felt  best  in  the 
fourth  or  fifth  space  within  the  nipple  line,  limited 
in  area  and  best  felt  during  expiration.  It  is  rough, 
grating  in  quality,  and  can  be  felt  to  terminate  in 
a  sharp,  sudden  shock,  synchronous  with  the  im- 
pulse. 

Eemember  that  the  enlarged  auricle  may  press 
upon  the  left  recurrent  laryngeal  nerve,  and  cause 
paralysis  of  the  vocal  cords  on  the  same  side. 

Eemember  that  the  murmur  is  heard  to  the  inner 
side  of  apex  beat  or  along  the  left  sternal  border, 
and  sometimes  can  be  heard  only  when  the  breath 
is  held.  It  is  a  rough,  vibratory,  or  purring  sound, 
and  gradually  becomes  louder  until  it  terminates  in 
the  first  sound.  This  murmur  is  synchronous  with 
the  thrill  felt  on  palpation. 


VALVULAR    DISEASE    OF   THE    HEART.  141 

Tricuspid  Insufficiency. 

Remember  that  tlie  signs  are  those  of  retarded 
pulmonary  circulation  and  visceral  congestion. 

Eemember  that  the  pulse  wave  is  seen  in  the  veins 
of  the  neck,  more  pronounced  in  the  right  jugular. 

Remember  that  often  an  expansile  pulsation  of 
the  liver  may  be  palpated.  This  may  best  be  de- 
tected by  bimanual  palpation.  One  hand  is  placed 
over  the  fifth  and  sixth  costal  cartilages,  the  other 
over  the  lower  border  of  the  liver  in  the  midaxillary 
line,  when  a  rhythmical  expansile  pulsation  may  be 
felt. 

Remember  that  a  low  systolic  murmur  is  heard 
best  over  the  lower  part  of  the  sternum  and  propa- 
gated in  the  direction  of  the  right  axilla. 

Crural  Vein  Sound.  A  valve  sound  may  be  heard 
over  the  crural  vein,  either  single  or  double.  If 
double,  it  corresponds  to  the  presystolic  and  systolic 
filling  of  the  vein. 

Tricuspid  Stenosis. 

Remember  that  this  condition  is  almost  invariably 
associated  with  tricuspid  insufficiency. 

Eemember  that  there  is  a  presystolic  murmur, 
best  heard  at  the  base  of  the  ensiform  cartilage. 

Remember  that  this  murmur  is  associated  with 
a  presystolic  thrill.  Cardiac  dullness  is  increased 
toward  the  right. 

Remember  that  cyanosis  of  the  face  and  lips  is 
commonly  seen,  and  becomes  pronounced  where 
dropsy  occurs. 


142        diseases  of  the  yasculak  system. 

Treatment  of  Valyular  Lesions. 

Remember  tliat  a  heart  with  a  lesion  does  not  need 
treatment  so  long  as  hypertrophy  overcomes  the  ill 
effects  of  the  lesion.  There  is  as  much  wisdom  in 
knowing  when  not  to  treat  cardiac  lesions  as  there 
is  in  knowing  what  to  do  when  active  treatment  is 
called  for;  hence  we  may  divide  the  treatment  into 
stage  of  compensation  and  stage  of  broken  compen- 
sation. 

Stage  of  Compensation. 

In  this  stage  the  treatment  is  wholly  dietetic  and 
mechanical. 

Diet.  The  food  should  be  abundant  and  nutri- 
tious. Coffee  may  be  allowed,  especially  in  the 
elderly.  Milk  should  form  a  good  part  of  the  diet, 
but  meats  of  all  kinds  are  allowable  in  moderation. 
Fruits  of  various  kinds  and  vegetables,  especially 
spinach,  lettuce,  carrots,  cauliflower. 

The  digestive  tract  must  be  watched,  that  gases 
do  not  form  in  the  stomach  and  interfere  with 
cardiac  action. 

Cathartics  should  occasionally  be  used,  and  sa-- 
lines  are  best,  unless  the  patient  is  greatly  weak- 
ened. 

Fluids  must  be  allowed  in  moderation.  It  is  bet- 
ter if  the  patient  takes  less  than  the  ordinary 
amount  in  health.  More  should  be  allowed  in  hot 
weather. 


VAIiVULAE,   DISEASE    OF   THE    HEAET.  143 

Tobacco  is  allowable  in  old  smokers,  as  it  will 
have  no  injurious  effects;  otherwise  it  is  best  to 
forbid  it. 

Salt  should  be  eliminated  as  much  as  possible 
from  the  food.  It  should  be  rigidly  withdrawn 
when  dropsy  appears. 

Rest  after  eating  should  always  be  insisted  upon, 
the  length  of  time  depending  upon  the  individual 
case. 

Exercise  should  be  moderate  and  in  the  open  air. 
Violent  or  long-exhausting  undertakings  must  be 
prohibited.  Worry  and  anxiety  are  never  allowable, 
and  the  patient  must  lead  a  quiet,  even  life. 

Baths.  The  skin  should  be  kept  active  and  free 
by  tepid  baths  or  sponging.  Hot  or  cold  baths 
should  not  be  used.  Turkish  baths  must  be  pro- 
hibited. 

Clothing.  Flannel  next  to  the  skin  is  best,  but 
care  not  to  dress  the  patient  too  warm  is  just  as 
important.  The  skin  must  be  protected  from  sud- 
den chilling,  as  this  causes  visceral  congestion  and 
increases  cardiac  work. 

Medica,tion  is  indicated  only  as  designed  to  tone 
up  the  whole  system.  For  anemia  and  as  a  general 
tonic  and  a  stomachic,  arsenic  is  excellent.  Fow- 
ler's solution  may  be  given,  or  combined  as  follows: 

3     Liquoris  potassii  arsenitis, 

Tincturse    Valerianae    aa  3  ij 

Misce. 

Sig. :    4    drops   in   water   three   times    daily.     Increase    1 
drop  per  day  until  8  drops  are  taken. 


144  DISEASES    OF   THE    VASCULAR    SYSTEM. 

Or: 

3     Arseni    trioxidi     gr.  iss 

Piperis    gr.  xv 

Acacise .  . .  gr.  ii  j 

Aquae     q.  s. 

Misce  et  fiant  pilulse  No.  XX. 

Sig. :  Pill  three  times  daily. 

Quinin  as  a  tonic  may  be  used,  but  it  is  not  so 
good. 

B     Tincturas  cinchonae  compositae   5  iv 

Sig. :  Teaspoonful  in  water  three  times  daily  before  meals. 

Or: 

R     Tincturse  cinchonae  compositae, 

Tincturae  gentianse  compositae    .  .  aa  §  ij 
Misce. 
Sig. :    Teaspoonful   three   times   daily  before  meals. 

Stage  of  Broken  Compensation. 

Rest  should  be  complete.  The  patient  should  be 
confined  to  his  bed. 

Diet.  So  long  as  digestion  is  good  or  hydrops  is 
not  present  the  diet  should  be  liberal.  When  either 
condition  appears,  the  diet  must  be  restricted.  Best 
— milk,  two  pints,  and  add  well-cooked  cereals, 
shredded  wheat  biscuits,  zwieback,  toasted  bread, 
and  unsalted  butter.  Later  soft  egg,  chicken,  quail, 
lamb,  or  veal  chops,  and  potatoes. 

Odd,  locally — either  the  ice  bag,  Leiter's  coil,  or 
cold  compress — should  be  laid  over  the  cardiac  re- 
gion. The  compress  should  be  changed  as  soon  as 
it  gets  the  least  warm. 

Cardiac  Stimulants.     The  best  is  digitalis.     It 


VALVULAR   DISEASE    OF   THE   HEART.  145 

slows  the  rate  and  strengthens  the  beat.  Don't  for- 
get its  cumulative  action.  The  effect  on  the  heart 
can  be  detected  as  long  as  nine  days  after  its  use. 
There  are  various  forms  and  preparations  in  which 
it  may  be  given. 

R     Infusi  digitalis    (fresh  leaves)    ....§iv 
Sig. :   Tablespoonful  every  two  or  three  hours. 

Or: 

R     Tincturas  digitalis, 

Tincturae  scillse    aa  3  iv 

Misce. 

Sig.:   20  to  30  drops  three  times  daily. 

Or: 

R     Digitaloni     Ill  xv 

Sig. :  May  be  given  every  four  hours  hypodermatically. 

Or: 

R     Digitalini     gr.  ss 

Alcoholis    TTL  XV 

Aquae     3  i  j 

Misce. 

Sig.:    Inject   10   to   20  minims  subcutaneously. 

Or: 

R     Potassii  acetatis  gr.  xx 

Tincturse   digitalis    TTL  xv 

Tincturae  scillae   TIX  xl 

Tincturse  nucis  vomicae   TTt  v 

Infusi    senegae    q.  s.  ad  §  j 

Misce  et  fiat  haustus. 

Sig.:   To  be  taken  every  four  hours. 

Or: 

R     Tincturse  scillae   3  iv 

Tincturae  digitalis    3  iij 

Aquae  cassiae   q.  s.  ad  §  vj 

Misce. 

Sig.:  Tablespoonful  every  four  hours. 


146  DISEASES   OF   THE   VASCULAR    SYSTEM. 

Remember  that  there  are  some  conditions  that 
contraindicate  digitalis,  or  that  require  the  drug  to 
be  administered  very  cautiously  or  in  combination 
with  other  drugs.  In  a  diseased  heart  muscle,  es- 
pecially in  aortic  incompetency,  it  should  be  given 
cautiously,  and,  no  improvement  following,  it  should 
be  abandoned. 

Fatty  degeneration  of  the  cardiac  muscle  and  an 
extensive  myocarditis  contraindicate  digitalis.  In 
an  abnormally  slow  heart,  to  be  determined  by 
cardiac  auscultation  and  not  by  the  radial  pulse, 
digitalis  should  be  combined  with  atropin  (Ortner), 
thus: 

IJ     Atropini    sulphatis     gr.  ^o~g^-  Veo 

Syrupi  rubi  idsei    5  iv 

Infusi   digitalis    q.  s.  ad  3  vj 

Misce. 

Sig. :    Tablespoonful  every  two  or  three  hours. 

In  cases  of  extensive  arteriosclerosis,  digitalis  is 
dangerous,  unless  the  peripheral  constriction  is 
counteracted.  Nitroglycerin  should  be  combined 
with  it,  thus: 

R     Tinctur£e  digitalis, 

Tincturse  nucis  vomicEe    aa  3  ij 

Spiritus  glonoini    TTl  xij 

Tincturse   cardamomi  comp.   q.  s.  ad  ^  iij 

Misce. 

Sig. :    Dessertspoonful   every  three  or  four  hours. 

Two  other  drugs  are  of  value,  either  when  digi- 
talis can  not  be  used  or  to  supplement  its  action. 
They  are  strophanthus  and  spartein. 


VALVULAR    DISEASE    OF   THE    HEART.  147 

Strophanthus  may  be  given  alone,  10  to  15  drops 
of  the  tincture,  or  as : 

R     Tincturae  strophanti, 

Tincturse   Valerianae    aa  o  i j 

Misce. 

Sig. :    10  to  30  drops  three  times  daily. 

Spartein  may  be  exhibited  in  solution,  powder,  or 
pills,  as: 

R     Sparteinse  sulphatis   gr.  iv 

Syrupi  aurantii    3  vj 

Misce. 

Sig.:   Tablespoonful  three  or  four  times  daily. 

Or: 

R     Sparteinse    sulphatis    gr-  'vj 

Glycyrrhizse     q.  s. 

Misce  et  fiant  pilulse  No.  XX. 

Sig. :   Pill  three  or  four  times  daily. 

With  sign  of  cardiac  failure — pulse  hardly  palpa- 
ble, heart  tones  weak,  and  the  extremities  cold  and 
livid — camphor  should  be  given  hypodermatically. 

R     Camphorag     3  ss 

Olei   olivae    3  ij 

Misce  et  fiat  solutio. 

Sig. :   Inject  5  minims  as  necessary. 

Venesection  is  life-saving  when  dilatation  occurs. 
When  signs  of  venous  engorgement  occur,  and  when 
there  is  orthopnea  with  cyanosis,  the  withdrawing 
of  from  20  to  30  ounces  of  blood  is  urgently  indi- 
cated. 

Dropsy  is  frequently  relieved  by  rest  and  a  course 
of  digitalis,  but  at  times  it  is  necessary  to  resort  to 
other  measures. 

Diuretics  are  then  indicated. 


148  DISEASES   OF   THE    VASCULAR    SYSTEM. 

Diuretin,  wliich  is  sodium  salicylate  of  theobro- 
min,  has  the  advantage  of  stimulating  the  renal 
epithelium  without  injury.  It  is  insoluble  in  cold 
water  and  is  best  given  in  powder,  as: 

IJ     Diuretini     gr.  x 

Fiat  pulvere  No.  I.     Dentur  tales  doses  iSTo.  XXV. 
Sig. :  Powder  every  three  hours. 

Or  it  may  be  given  in  solution,  as  diuretin  is 
soluble  in  hot  water,  as: 

I^     Diuretini     5  j-o  iss 

Essentise  pepsini    (Fairehild)     §  ij 

Aquae     5  v 

Dissolve  diuretin  by  slightly  heating  water. 

Misce  et  fiat  solutio. 

Sig.:    Tablespoonful   every  two  hours. 

Theocin-sodium  acetate  gr.  iij-gr.  v  four  to  six 
times  daily,  and  should  not  be  given  on  an  empty 
stomach. 

Calomel  in  many  cases  produces  marked  diuresis. 
The  effect  usually  begins  three  or  four  days  after 
beginning  treatment  and  continues  four  or  five  days 
after  treatment  stops.  It  should  be  given  only  for 
three  or  four  days  and  then  stopped  for  an  equal 
length  of  time.  When  it  causes  diarrhea,  this  may 
be  overcome  by  giving  gtt.  iij-gtt.  v  of  deodorized 
tincture  of  opium  with  it.  Hydrogen  peroxid  should 
be  used  as  wash  for  the  mouth  during  the  adminis- 
tration. 

R     Hydrargyri  chloridi  mitis    gr.  ii j 

Sacchari  lactis    gr.  vj 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  doses  No.  X-XII. 
Sig.:    Powder  three  times  daily. 


VALVULAR    DISEASE    OF    THE    HEART.  149 

If  the  pulse  is  weak,  it  is  better  to  administer  digi- 
talis three  or  four  days  before  giving  the  calomel. 
Addison's  or  Niemeyer's  pills  are  excellent,  as  they 
are  a  combination  of  digitalis,  calomel,  and  squills 
aa  gr.  j.  One  pill  should  be  given  three  or  four 
times  a  day  for  four  or  five  days.  Care  should  be 
used  because  of  salivation  if  continued  for  too  long 
a  time. 

Cathartics  may  be  used  to  remove  dropsy,  and 
of  these  concentrated  solutions  of  the  salines  are 
best.  Strong  purges,  like  colocynth,  should  be 
avoided. 

Multiple  incisions  or  paracentesis  is '  at  times 
necessary  to  get  rid  of  the  dropsy,  and  should  be 
resorted  to  when  other  measures  fail. 

Insomnia.  A  cup  of  hot  gruel  at  bedtime,  a  tepid 
bath,  or  a  light  evening  meal  will  be  all  that  is  neces- 
sary in  many  instances.  Sodium  bromid  may  be 
used. 

IJ.     Sodii  bromidi    5  ij 

Syrupi  rubi  idsei 5  iss 

Aquae    q.  s.  ad  S  iv 

Misce. 

Sig. :    Tablespoonful    in   evening   and   repeat    in    hour    if 
necessary. 

If  salt  is  withheld  from  the  food,  better  effect  of 
the  bromid  will  be  obtained,  as  salt  hastens  elimi- 
nation; a  good  point,  also,  to  remember  in  cases  of 
bromism. 

Bromipin  in  from  2  to  4-dram  doses  in  the  after- 
noon and  evening  often  acts  better  than  bromids. 


150  DISEASES   OF   THE   VASCULAR    SYSTEM. 

Veronal  is  a  good,  safe  hypnotic.  Best  given  in 
glass  of  milk.  It  may  be  given  in  5-grain  doses  and 
repeated  in  one  to  two  lionrs. 

Congh  is  almost  always  present.  When  it  be- 
comes annoying,  codein  gr.  ^  should  be  given.  An 
excellent  combination  is  a  tablet  put  up  by  Abbott, 
of  Chicago,  and  has  the  following  formula: 

IJ     Zinci    sulpliocarbolatis    gr.  j 

Codeini    sulphatis    gr.  14 

Hyoscyaminaj  liydrobromatis    gr.  %5q 

Stryclminae   sulphatis    gr.  ^,{34 

Misce  et  fiat  tabella  No.  I. 

Sig. :   Tablet  every  one  or  two  hours. 

The  SchoU  Movements. 

The  Schott  or  Nauheim  system  of  treatment  of 
cardiac  affections  consists  in  the  proper  resistance 
exercise.  The  exercise  is  such  that  different  groups 
of  muscles  work  against  a  gentle  resistance  of  the 
physician  or  attendant.  Careful  watch  must  be  kept 
during  the  movements,  and  on  any  sign  of  circula- 
tory or  respiratory  trouble  the  movements  are  at 
once  suspended. 

The  following  are  some  of  the  movements  used, 
each  exercise  being  made  against  slight  resistance 
applied  by  the  physician: 

1.  The  arms  are  extended  in  front  of  the  body  at 
the  level  of  the  shoulder,  with  the  palms  touching. 
The  arms  are  then  moved  slowly  outward  until  they 
are  in  a  line  with  each  other,  and  are  then  brought 
forward  to  the  original  position. 


VALVULAR    DISEASE   OF   THE   HEART.  151 

2.  The  arms  and  hands  hang  at  the  side,  with 
the  palms  forward.  The  forearm  is  flexed  upon  the 
arm  until  the  fingers  touch  the  shoulder.  The  fore- 
arm is  then  extended  to  its  original  position.  This 
exercise  is  first  done  with  one  arm  and  then  with 
the  other. 

3.  The  arms  and  hands  in  position  as  in  No.  2. 
The  arms  are  raised  until  the  tliumbs  meet  over  the 
head  and  then  return  to  original  position. 

4.  Same  as  No.  3,  except  fingers  are  flexed  at 
first  phalangeal  joint. 

5.  Arms,  hanging  in  position  of  ^'attention,"  are 
brought  forward  parallel  to  each  other  until  they 
are  elevated  to  a  vertical  position,  and  then  re- 
turned to  original. 

6.  Same  as  No.  1,  except  with  fists  clenched. 

7.  Same  as  No.  2,  except  with  fists  clenched. 

8.  The  arms,  starting  from  the  position  of  "atten- 
tion," describe  a  circle  by  moving  forward  and  up- 
ward until  they  are  raised  vertically;  then  each 
palm  is  turned  outward  and  the  arms  descend  back- 
ward to  their  original  position. 

9.  The  body  is  bent  forward  and  then  brought 
back  to  the  erect  position,  the  knees  not  being 
moved. 

10.  The  body  is  rotated  first  to  the  right  and  then 
to  the  left  without  any  movement  of  the  feet. 

11.  The  body  is  flexed  first  to  the  right  and  then 
to  the  left  as  far  as  possible  without  moving  the 
feet. 


152  DISEASES   OF   THE    VASCULAK    SYSTEM. 

12.  The  patient  in  the  erect  posture,  feet  close  to- 
gether, and  one  hand  resting  on  a  support,  the  oppo- 
site thigh  is  flexed  as  far  as  possible,  then  extended, 
and  foot  brought  into  its  original  position.  The 
other  hand  is  placed  on  a  support  and  the  opposite 
thigh  is  flexed  the  same  as  the  other. 

Palpitation. 

Remember  that  this  is  more  frequently  found  in 
women,  and  hysteria  is  often  the  causative  factor. 

Remember  that  dyspepsia,  especially  if  associ- 
ated with  neurasthenia,  is  often  the  cause. 

Remember  that  the  symptoms  vary  from  a  mild 
form,  as  seen  in  dyspeptic  attacks,  when  there  is 
slight  fluttering  of  the  heart,  to  the  severe  forms, 
when  cardiac  action  is  violent  and  the  arteries 
throb  forcibly. 

Remember  that  the  pulse  rate  may  be  high — 
150  to  160 — with  diffuse  flushing  of  the  skin.  A 
large  quantity  of  pale  urine  may  be  passed  after 
such  an  attack. 

Remember  that  the  presence  of  a  diastolic  mur- 
mur excludes  nervous  palpitation. 

Remember  that  the  area  of  cardiac  dullness  is 
not  enlarged,  thus  excluding  hypertrophy. 

Remember  that  the  fact  of  intervals  between  at- 
tacks, when  the  patient  is  free  of  palpitation,  is 
strongly  suggestive  of  neurosis. 

Remember  that  if  the  patient  is  anemic,  murmurs 
will  be  heard — systolic,  soft,  blowing — but  the  valve 


PALPITATION.  153 

sounds  will  be  normal  and  there  will  be  no  hyper- 
trophy of  the  heart. 

Treatment. 

First,  quiet  the  patient's  fears  by  assuring  him 
that  there  is  no  actual  danger.  Second,  seek  out 
the  cause,  and  inaugurate  the  proper  hygienic  and 
dietetic  regimen. 

Regular  hours  should  be  kept,  and  ten  hours  of 
sleep  insisted  upon.  Tepid  bath,  at  night  if  nervous, 
or  in  the  morning  on  arising.  The  evening  meal 
must  be  light — mainly  soups. 

Sexual  excitement  is  particularly  prone  to  keep 
up  the  trouble  and  patients  should  be  specially 
warned.  A  Weir-Mitchell  course  of  treatment  is 
best  where  neurasthenia  is  the  causative  factor  in 
women.  Anemia  demands  iron.  The  following 
formulae  are  good : 

IJ     Ferri  et  quiniiiEe  citratis gr.  xl-gr.  Ix 

Liquoris   strychninse    TT],  xl 

Spiritus  chlorof ormi    3  i j 

Acidi  hydrobromici    TTL  Ixx 

Aquse    q.  s.  ad  3  iv 

Misce. 

Sig. :  Tablespoonful  three  times  a  day  before  meals. 


Or: 


3     Ferri  et  ammonii  citratis   gr.  Ixx 

Tincturae   nucis   vomicae    3  iss 

Sodii  bromidi    9  iv 

Spiritus  ammonii  aromatici    3  iv 

Aquse    q.  s.  ad  3  iv 

Misce. 

Sig.:  Tablespoonful  three  times  daily. 


154  DISEASES   OF   THE   VASCULAE    SYSTEM. 

When  gastric  disturbances  are  the  cause,  as  seen 
in  distention  of  the  stomach  by  gas  formed  by  the 
decomposition  of  food,  medication  directed  toward 
the  prevention  of  the  gas  formation  is  indicated. 

IJ     Bismuthi    carbonatis     gr.  x 

Magnesii   carbonatis    gr.  v 

Sodii   bicarbonatis    gi"-  x 

Aquae  laurocerasi    3  j 

Aquse    caryopliilli    q.  s.  ad  §  j 

Misce  et  fiat  haustus. 
Sig. :  To  be  taken  two  times  a  day  an  hour  before  meals.  (Yeo.) 

Or: 

IJ,     Phenolis    gr.  xv 

Glycerini    3  v 

Bismuthi   carbonatis    3  iiss 

Lactis  magnesii   q.  s.  ad  §  iv 

Misce. 

Sig. :   Two  teaspoonfuls  after  meals. 

Aconite  or  veratrum  viride  may  be  used  where 
there  is  great  rapidity  of  cardiac  action. 

Digitalis  is  seldom  indicated,  but  in  obstinate 
cases  it  may  be  given  in  combination  with  nux 
vomica. 

Eemember  that  strychnin,  in  the  form  of  tincture 
of  nux  vomica,  and  given  in  large  doses,  20  drops 
three  times  daily,  gives  the  best  results  in  most 
cases. 

Angina  Pectoris. 

E,emember  that  this  condition  occurs  almost  ex- 
clusively in  men,  and,  when  occurring  under  thirty- 
five,  syphilitic  aortitis  is  an  important  factor. 


ANGINA    PECTORIS.  155 

Remember  that  gout  and  diabetes  are  important 
etiologic  factors,  and  angina  pectoris  has  been 
known  to  follow  influenza. 

Remember  that  arteriosclerosis  is  present  in 
practically  all  the  cases,  but  the  degree  of  sclerosis 
of  the  palpable  arteries  is  no  criterion  of  the  degree 
of  degeneration  of  the  coronary  vessels. 

Remember  that  in  angina  an  attack  is  usually 
caused  by  sudden  exertion,  mental  worry,  exposure 
to  cold,  or  a  hearty  meal. 

Remember  that  the  onset  is  sudden  and  usually 
without  any  warning. 

Remember  the  three  essential  phenomena: 

1.  Pain,  agonizing,  felt  in  the  precordium  and  be- 
neath the  manubrium.  The  pain  radiates  to  the 
neck  and  into  the  left  arm  along  the  distribution  of 
the  ulnar  nerve. 

2.  The  sense  of  constriction  of  the  heart — feeling 
as  though  the  heart  were  being  ''grasped  by  a 
mailed  hand." 

3.  The  sense  of  impending  death.  The  face  is 
pallid,  gray,  and  bathed  in  sweat. 

Remember  that  death  may  occur  during  an  at- 
tack. 

Remember  that  paroxysms  may  occur  frequently 
or  at  long  intervals  of  time 

Remember  that  there  is  a  neurotic  form  that  close- 
ly simulates  true  angina. 

Remember  that  the  neurotic  form  occurs  more  fre- 
quently  in   women — periodically;   that   the   attack 


156  DISEASES    OF   THE   VASCULAR    SYSTEM. 

lasts  one  or  two  hours,  during  whicli  there  is  agita- 
tion and  activity,  associated  with  nervous  symp- 
toms, and  is  never  fatal. 

Treatment. 
During  an  Attach. 

Nitrite  of  amyl  by  inhalation  frequently  gives  re- 
lief; from  3  to  5  minims  on  handkerchief  or  sponge 
may  be  inhaled.  Patient  should  carry  the  ' '  pearls, ' ' 
and  be  instructed  to  break  one  and  inhale  from 
handkerchief  on  first  signs  of  an  attack. 

Chloroform  inhalation  should  be  resorted  to  if 
"  amyl  nitrite  inhalations  do  not  give  relief.  Usually 
this  is  the  most  effective  way,  and  it  is  free  of 
danger. 

Morphin  hypodermatically  may  be  used,  but  bear 
in  mind  that  it  requires  a  large  dose  to  give  relief. 
Give  at  least  gr.  ^-gr.  ss  combined  with  atropin 
sulphate  gr.  M.00. 

Interval  Treatment. 

Patients  should  live  a  quiet  life,  free  from  worry 
and  excitement.  Muscular  exertion  must  not  be 
sudden  or  prolonged. 

Substances  that,  in  the  course  of  time,  have  a 
toxic  action  on  the  heart  must  be  avoided,  as  these 
substances  may  be  the  cause  of  severe  attacks  of 
angina.  This  is  particularly  true  of  tobacco,  and 
the  peculiar  thing  about  it  is  that  the  patient  may 
use  tobacco  for  years  without  any  apparent  ill  effect 


ANGINA    PECTORIS,  157 

until,  arriving  at  midlife,  it  begins  to  manifest 
its  toxic  action.  Tea  and  coffee  are  likewise  harm- 
ful, and  should  be  excluded. 

Elimination  is  exceedingly  important  in  the 
treatment.  Toxic  substances  absorbed  from  the 
bowels  are,  without  doubt,  potent  factors  in  caus- 
ing high  blood  pressure  and  vascular  sclerosis. 
Many  of  the  cases  give  a  history  of  dyspepsia  of 
long  duration. 

Diet  is,  therefore,  important,  and  should  be  light 
and  nutritious.  An  exclusive  milk  diet  for  a  while 
is  excellent.  Cream  should  be  added  to  the  milk. 
Fresh  vegetables  and  fruits  are  indicated.  Eggs, 
butter,  and  the  lean  of  fresh  meat  minced  and 
lightly  cooked  may  be  allowed. 

Regular  evacuation  of  bowels  is  very  essential, 
because  it  will  check  the  formation  of  injurious  sub- 
stances. Aperient  waters  or  salines  may  be  used. 
An  excellent  dinner  pill  may  be  exhibited  as  follows : 

R     Extract!  aloes, 

Pulveris  ipecaeuanlise^ 

Pulveris  nucis  vomicae, 

Saponis    aa  gr.  j 

Misce  et  fiat  pilula  No.  I.     Dentur  tales  No.  XXV. 
Sig. :   Pill  morning  and  evening. 

Nitroglycerin  should  be  given  for  its  relaxing 
action  upon  the  blood  vessels;  it  may  be  given  in 
doses  of  gr.  %oo  and  gradually  increase  until  effect. 

Spirits  of  glonoin  may  be  used,  which  represents 
Yioo  grain  of  nitroglycerin  to  the  minim.  Begin 
with  1  minim  three  times  daily  and  increase  1  minim 


158  DISEASES   OF   THE   VASCULAE    SYSTEM. 

every  fifth  day  until  the  patient  complains  of  flush- 
ing or  headache. 

lodids,  either  the  potassium  or  sodium,  admin- 
istered for  one  or  two  years,  stopping  ten  days  in 
each  month,  are  excellent. 

IJ     Sodii  iodidi    3  iiss 

Sodii  arsenatis    gr-  % 

Aquse   destillatse    q.  s.  ad  §  v 

Misce. 

Sig. :  Teaspoonful  three  times  daily. 

Or: 

IJ     Tincturae    digitalis 3  j 

Tincturai   strophanti    3  j 

Spiritus  glonoini    (1 -percent)    Tr|,  xxiv 

Tincturae   cardamomi    q.  s.  ad  o  iij 

Misce. 

Sig.:  Teaspoonful  three  times  daily. 

Or: 

IJ     Potassii  iodidi, 

Aquse    aa  o  j 

Sig. :  20  drops  three  times  daily,  stopping  for  a  week  in 
each  month,  but  continuing  the  treatment  for  a  couple  of 
years. 

Water  should  be  drunk  liberally,  unless  the  kid- 
nej^s  are  so  affected  that  elimination  is  interfered 
with. 

Arteriosclerosis. 

Remember  that  the  history  of  the  patient  gone 
into  carefully  often  reveals  the  cause.  Syphilis, 
gout,  arthritis,  and  heredity  are  the  chief  causes. 

Remember  that  this  is  a  change  common  to  old 
age,  and  is  similar  to  the  sclerotic  changes  of  other 
tissues. 


ARTEKIOSCLEROSIS.  159 

Remember  that  the  two  classes  of  men  most 
likely  to  develop  it  are  the  laborer  who  does  heavy, 
muscular  work,  and  the  brain  worker  who  is  sub- 
ject to  a  great  amount  of  worry. 

Remember  that  high  blood  pressure,  a  palpable 
thickening  of  the  arteries,  hypertrophy  of  the  left 
ventricle  of  the  heart,  and  the  accentuation  of  the 
aortic  second  sound  are  pathognomonic  of  arterio- 
sclerosis. 

Remember  that  there  are  renal  symptoms  in  some 
of  the  cases — viz.:  increased  amount  of  urine,  tran- 
sient albuminuria,  and  few  hyaline  tube  casts. 

Remember  that  in  some  cases  the  cardiac  hyper- 
trophy is  followed  by  dilatation,  and  a  murmur  can 
be  heard  at  the  apex. 

Remember  that  when  the  hypertrophy  fails  to 
compensate  for  the  arterial  resistance,  there  will  be 
dyspnea,  vertigo,  and  chronic  bronchitis. 

Remember  that  the  subsequent  symptoms  depend 
upon  the  location  of  the  sclerosis  in  the  vascular 
area. 

Remember  that  sclerosis  of  the  coronary  arteries 
may  lead  to  thrombosis  and  sudden  death,  or  aneu- 
rism of  the  heart,  or  angina  pectoris. 

Remember  that  if  the  cerebral  vessels  are  the  seat 
of  extensive  sclerosis,  we  may  have  transient  hemi- 
j)legia,  monoplegia,  or  aphasia. 

Remember  that  these  attacks  are  transient,  last- 
ing usually  less  than  twenty-four  hours,  with  perfect 
recovery,  and  may  be  followed  later  by  a  recurrence. 


160  DISEASES   OF   THE    VASCULAE    SYSTEM. 

E-emember  that  vertigo,  slow  pulse,  and  epilepti- 
form attacks  may  occur. 

Eemember  that  intermittent  claudication  is  very 
common.  It  is  an  intermittent  lameness  caused  by 
muscular  activity  of  certain  groups  of  muscles  of  the 
limbs,  followed  by  cramps. 

Teeatment. 

Early  diagnosis  is  necessary  if  anything  of  per- 
manent value  in  treatment  is  to  be  done. 

Diet  should  consist  largely  of  milk  and  its  prod- 
ucts, with  vegetables  and  fruits.  Meat  should  be 
reduced  to  the  minimum. 

A  quiet  life,  free  from  worry,  and  moderate  open 
air  exercise  is  indicated. 

Baths  of  room  temperature  or  sponging  is  excel- 
lent. Massage  of  the  abdomen  and  extremities,  if 
long  continued,  will  lower  the  blood  pressure. 

The  bowels  should  be  kept  open  by  vegetable  or 
saline  cathartics. 

The  kidneys  must  be  kept  active.  For  this  pur- 
pose theobromin  is  useful. 

E     Theobromini     gi".  X 

Fiat  dosis  No.  I.   Dentur  tales  doses  No.   XXX.     Dispense 
in  gelatin  capsules. 

Sig. :    Capsule  four  to  six  times  daily. 

Other  diuretics,  described  under  heart  disease, 
may  be  used  if  necessary. 

lodids  and  arsenic  are  the  two  drugs  that  give 
best  results. 


ARTERIOSCLEROSIS.  161 

IJ     Potassii  or  sodii  iodidi   3  i  j  vel  3  iv 

Sodii  bicarbonatis    gr.  Ixxv 

Aquae  menthse  piperitse, 

Aquae   destillatae    aa  §  iiss 

Misce  et  fiat  solutio. 

Sig. :    Tablespoonful   after   meals. 

Vierordt  advises  2  or  3  grains  of  sodium  iodid 
three  times  daily  and  gradually  increase  the  dose 
until  15  grains  three  times  daily  are  taken.  This  is 
kept  up  for  from  one  to  three  years,  omitting  the 
treatment  one  week  in  five. 

Calomel  purge,  frequently  given,  will  greatly  aid 
in  the  plan  of  treatment. 

With  a  feeble  heart  the  following  combination  is 
good: 

B     Sodii    iodidi     3  j 

Sparteine    sulphatis    gr.  xv 

Pulveris  glycyrrhizae    q.  s. 

Misce  et  fiant  pilulse  Xo.  XL. 

Sig.:  Pill  after  meals. 

Arsenic  may  be  exhibited  as  Fowler's  solution,  or 
as  in  the  following: 

I^     Arseni  trioxidi gr.  ss 

Ferri    reducti    gr.  xxx 

Euquinini    ( Merck )    3  j 

Extract!  rhamni  purshianae   3  iss 

Misce  et  fiant  pilulae  Xo.  XXX. 

Sig. :  Pill  after  each  meal. 


Or: 


I^     Potassii   iodidi    3  iv 

Ammonii    chloridi    3  j 

Syrupi  sarsaparillse  compositse  ....  §  j 
Aquae  destillatae   q.  s.  ad  §  ij 

Misce. 

Sig. :   Teaspoonful  in  milk  after  meals. 


162  DISEASES   OF   THE   VASCULAR    SYSTEM. 

If  cardiac  insufficiency  manifests  itself,  tonics  are 
indicated,  and  of  these  perhaps  tincture  of  digitalis 
in  10-minim  doses,  combined  with  1  minim  of  spirits 
of  glonoin,  three  times  daily,  or  of tener  if  the  symp- 
toms are  urgent. 

Venesection,  with  abstraction  of  20  ounces  of 
blood,  gives  immediate  relief  in  cases  of  engorge- 
ment. The  amount  of  blood  withdrawn  should  not 
be  replaced  with  the  saline  solution,  as  it  is  the  re- 
duction of  the  circulating  liquid  that  is  desired. 


CHAPTER  X. 

DISEASES  OF  THE  LUNGS  AND  PLEURA. 

Acute  Bronchitis. 

Remember  that  in  typhoid  and  malaria  it  is  an 
early  symptom. 

Remember  that  influenza,  measles,  and  whooping- 
cough  are  accompanied  by  acute  bronchitis. 

Remember  that  substernal  soreness  and  in  the 
region  of  the  attachment  of  the  diaphragm  is  com- 
nion,  and  is  due  to  cough. 

Remember  that  fever  is  frequently  present,  and 
may  reach  102°  or  103°  F.,  but  usually  lasts  only  a 
few  days. 

Remember  that  cough  is  ''tight"  in  early  part  of 
attack,  due  to  tenacious,  scanty  mucus  adhering  to 
swollen  mucosa  of  the  tubes. 

Remember  that  sibilant  or  sonorous  rales  are 
heard  during  this  period  of  dry  cough. 

Remember  that  the  larger  the  bronchi  affected, 
the  less  are  generally  the  signs  caused  by  the  bron- 
chitis. 

Remember  that  the  percussion  sound  over  the 
thorax  is  never  altered  by  uncomplicated  bronchitis. 

Remember  that  blowing  sounds  are  never  heard 
in  bronchitis,  but  that  the  vesicular  murmur  is 
heard,  and  the  only  alteration  is  that  it  is  sharp  and 
loud  (puerile),  and  there  is  prolonged  expiration. 

163 


164        DISEASES   OF    THE    LUIStgS   AND    PLEURA. 

Remember  that  mucous,  bubbling  rales  appear 
when  the  cough  loosens.  Bronchial  fremitus  may 
be  felt  on  palpation. 

Remember  that  cyanosis  and  increased  respira- 
tory rate  in  dyspnea  that  are  not  relieved  by  the 
cough  indicate  the  process  has  involved  the  small 
tubes — capillary  bronchitis. 

Remember  that  the  epigastrium  and  hypochon- 
driac region  are  retracted  during  inspiration  in  capil- 
lary bronchitis,  in  contradistinction  to  the  normal 
inspiratory  bulging.  ^ 

Remember  that  the  percussion  sound  is  not  al- 
tered. If  dull  areas  are  found,  it  signifies  bronchi- 
pneumonia  or  atelectasis.  Therefore  examine  such 
a  chest  daily  for  this  important  change  in  percus- 
sion. 

Remember  that  bronchial  breathing  heard  on  aus- 
cultation is  never  present  in  any  form  of  bronchitis. 

Remember  that  spirals  are  found  in  the  sputum 
in  capillary  bronchitis;  also  Charcot's  crystals. 

Treatment. 

In  mild  cases,  hot  foot  bath,  a  mustard  plaster  to 
the  chest,  applied  over  the  sternum  and  extending 
out  to  nipple  line  on  either  side.  The  plaster  should 
not  remain  on  long  enough  to  blister.  A  glass  of  hot 
lemonade  at  bedtime  will  suffice  in  mild  cases.  For 
the  severer  forms  a  hot  bath  at  night  on  going  to 
bed.  When  Turkish  baths  are  taken,  one  must  go 
directly  from  the  bath  to  bed,  because  any  exposure 
after  such  a  bath  is  exceedingly  dangerous. 


ACUTE    BRONCHITIS.  165 

Bowels  should  be  moved  freely  by  saline. 

The  atmospbere  of  tbe  room  should  be  moist.  This 
may  be  done  by  steam  from  boiling  water.  This  is 
better  if  salt  (NCI)  and  soda  are  added  to  it. 

The  cough  may  be  relieved  by  opium,  or,  better, 
codein.  In  the  dry  stage  the  secretion  of  mucus 
must  be  stimulated. 

IJ     Codeinse  phosphatis    gr.  v-gr.  viij 

Liquoris  anunonii  acetatis   3  iv 

Syrupi    ipecacuanhse    o  ij 

Syrupi  pruni  virginianse   3  iv 

Aquae     q.  s.  ad  5  iv 

Misce  et  fiat  solutio. 

Sig. :  Teaspoonful  every  two  hours. 

Or: 

IJ     Ammonii   carbonatis    3  ij 

Ammonii   iodidi    5  iij 

Syrupi  glycyrrhizse    §  ij 

Syrupi   tolutani    5  i j 

Misce  et  fiat  solutio. 

Sig. :   Teaspoonful  every  two  or  three  hours  in  water. 

The  above  combinations  are  particularly  useful  in 
capillary  bronchitis. 

IJ     Ammonii  chloridi, 

Sodii   salicylatis    aa  3  ij 

Tincturae  hyoscyaminse    3  vj 

Misturse  glycyrrhizse   comp.   q.  s.  ad  o  iij 
Misce. 
Sig. :   Teaspoonful  every  three  hours. 

Or: 

IJ     Codeinse  phosphatis   gr-  iv 

Ammonii   carbonatis    gr.  jcxx 

Tincturse  hyoscyaminse    3  iv 

Syrupi  pruni  virginianse 3  vj 

Aquse   camphorse    q.  s.  ad  §  ij 

Misce. 

Sig.:    Teaspoonful  every  two  hours. 


166        DISEASES   OF  THE    LUNGS   AND    PLEURA. 

Or: 

3     Vini    antimonialis    3  ij 

Spiritus  setheris  nitrosi 3  iv 

Liquoris  ammonii  acetatis   §  ij 

Tincturse  camphorse  compositse   .  . .  .  3  ij 

Aquae    q.  s.  ad  5  iv 

Misce. 

Sig. :    Tablespoonful    every    three    or    four   hours.     To  be 
used  with  tense  pulse,  fever,  and  dry,  hot  skin. 

With  the  establishment  of  secretion,  the  medica- 
tion should  be  changed.  This  is  now  the  time  for 
squills  and  senega,  but  they  are  contraindicated 
until  this  stage  is  reached. 

IJ     Infusi    senegse    5  iv 

Ammonii    carbonatis    gr.  xxxi j 

TincturiB    scillas    3  iiss 

Spiritus   chloroformi    3  ij 

Aquae    q.  s.  ad  5  viij 

Misce  et  fiat  misturae. 

Sig.:   2  tablespoonfuls  every  four  hours. 

Or: 

IJ     Tincturae   veratri   viridi    Til  xx 

Vini    antimonialis    3  iv 

Tincturae  opii  camphoratae   3  iiss 

Liquoris  ammonii  acetatis    5  ij 

Misce. 

Sig.:  Teaspoonful  in  little  water  every  two,  three,  or  four 
hours. 


Or: 


IJ     Camphorae    gr.  j 

Extracti   belladoimae    gr.  %-gr.  ^ 

Quininae   sulphatis    gr.  ij 

Pulveris   ipecacuanhse  et  opii gr.  j 

Misce  et  fiat  capsula  No.   I.     Dentur  tales  No.  XV. 

Sig.:    Capsule  hourly  for  four  doses,  then  every  three  hours. 


ACUTE  BROlSrCHITIS CHRONIC  BRONCHITIS.      167 

Or: 

IJ     Ammonii    cliloridi    3  j 

Terpini  hydratis   3  j 

Pulveris  ipecacuanhae  et  opii gr.  xxiv 

Misce  et  fiant  capsulse  No.  XXIV. 

Sig. :  1  or  2  capsules,  according  to  age,  every  three  hours. 


Or: 


Iji     Ammonii    chloridi    3  i j 

Potassii   iodidi    gr.  xv 

Tincturae   ipecacuanhae    TT1_  xxx 

Misturae  glycyrrhizae  comp.   q.  s.  ad  §  iv 

Misce. 

Sig.:   Tablespoonful  every  four  hours  during  dry  stage. 

Or: 

IJ     Syrupi  ipecacuanhas  3  iv 

Ammonii    chloridi    3  iv 

Tincturae  opii  camphoratse    3  ij-3  iij 

Syrupi   tolutani    q.  s.  ad  §  ij  • 

Misce. 

Sig. :  Teaspoonful  every  two  hours  as  a  sedative  expectorant. 

Aconite  may  be  used  for  reduction  of  fever.  It 
should  not  be  used  in  old  people  or  in  cases  where 
the  heart  is  weak. 

Diet  should  be  light.  Liquid  for  a  few  days  is 
best.  Tonics  may  be  needed  during  convalescence, 
and  there  is  nothing  better  than  elixir  of  iron, 
quinin,  and  strychnin,  a  teaspoonful  after  meals. 

Chronic  Bronchitis. 

Remember  that  this  is  often  secondary  to  other 
conditions,  as  emphysema,  heart  disease,  typhoid 
fever,  and  phthisis. 

Remember  that  occupation  is  a  very  important 


168       DISEASES    OF    THE    LUNGS   AND    PLEURA. 

factor  in  its  causation — such  occupations  where 
gases  or  dust  are  inhaled. 

Remember  that  it  is  common  in  the  gouty  condi- 
tions, often  spoken  of  as  uric  acidemia. 

Remember  that  this  is  a  disease  of  the  aged  and 
is  the  well-known  "winter's  cough"  of  old  men. 

Remember  that  there  are  two  forms — viz.,  dry 
and  moist,  the  latter  also  known  as  bronchorrhea. 

Remember  that  the  dry  is  characterized  by  severe 
fits  of  coughing,  with  very  little  secretion  brought 
up. 

Remember  that  shortness  of  breath  on  exertion, 
so  common  in  these  cases,  is  due  to  an  associated 
emphysema  or  cardiac  weakness. 

Remember  that  the  sputum  is  usually  purulent 
or  mucopurulent,  and  generally  abundant. 

Remember  that  inspection  shows  a  distended 
chest  with  limited  movement,  due  to  coexisting  em- 
fjhysema. 

Always  examine  the  heart  and  urine  in  all  cases 
of  chronic  bronchitis  to  determine  whether  the  bron- 
chitis is  primary  or  secondary. 

Remember  that  in  pulmonary  tuberculosis,  fever, 
emaciation  or  loss  of  weight,  localized  consolida- 
tion at  one  or  both  apices,  and  the  tubercle  bacilli 
are  present. 

Remember  that  in  abscess  of  the  lung  and  in  pul- 
monary gangrene  shreds  of  lung  tissue  may  be  pres- 
ent in  the  sputum. 


chronic  bronchitis.         169 

Treatment. 

The  patient  should  be  sent  to  a  warm  climate, 
especially  for  the  winter  months,  if  possible.  Dur- 
ing cold  or  wet  weather  he  should  remain  indoors, 
but  should  be  in  the  open  air  on  all  mild,  sunny 
days. 

Flannel  should  be  worn  next  to  the  skin.  The  diet 
should  be  nutritious  and  easy  of  digestion. 

The  bowels  should  be  kept  open  by  laxatives  if 
necessary.  Salines,  with  an  occasional  calomel 
purge,  is  best. 

In  cases  of  dry  bronchitis  it  is  better  that  the 
atmosphere  of  the  room  be  kept  moist  by  vapors. 

The  medicinal  treatment  depends,  first,  upon 
whether  it  is  a  dry  or  moist  catarrh,  and,  second, 
upon  the  underlying  condition  causing  it.  In  dry 
catarrh  the  following  are  useful: 

R     Sodii   bicarbonatis    3  j 

Sodii  chloridi    3  ss 

Ammonii   carbonatis    3  ss 

Spiritus  chloroformi    3  ij 

Aquae     q.  s.  ad  §  vj 

Misce  et  fiat  misturas. 

Sig. :  2  tablespoonfuls  every  four  hours  in  equal  amount  of 
water. 


Or: 


R     Pulveris   ipecacuaubse    gr.  j 

Extract!  hyoscyaminse   gr.  j 

Codeinae  phosphatis    gr.  ss 

Misce  et  fiat  pilula  No.  I. 

Sig. :  Pill  at  bedtime  for  cough. 


170         DISEASES    OF    THE    LUNGS    AND    PLEURA. 

Or: 

IJ     Potassii   iodidi    3  ss 

Potassii    bicarbonatis     S  ss 

Ammonii    chloridi    3  ij 

Codeince  phosphatis    gr.  viij 

Aquae  chloroformi    q.  s.  ad  §  viij 

Misce  et  fiat  mistiirse. 

Sig. :  Teaspoonf ul  every  two  hours  or  tablespoonful  every 
four   liours. 

Or: 

B     Olei  eucalypti    3  iss-3  iij 

Codeinae  phosphatis    gr.  vj 

Misce  et  fiant  capsulse  No.  XVIII. 

Sig.:   Capsule  every  four  hours.  ^ 

Or: 

3     Balsami    copaibse    3  j-3  ij 

Ammonii  chloridi   3  i j 

Extracti  glycyrrhizse  pulveris   3  j 

Misturae  ammoniacae   q.  s.  ad  5  iij 

Misce  et  fiat  misturae. 

Sig.:   Dessertspoonful  every  four  hours. 

In  moist  catarrh  the  expectorants  recommended 
in  acute  bronchitis,  or: 

IJ     Terpini  hydratis   gr.  xv 

Alcoholis, 

Aquae, 

Syrupi  rubi  idaei   aa  B  iss 

Misce. 

Sig.:   Tablespoonful  five  times  daily. 

Turpentine  is  excellent,  but  the  kidneys  should  be 
watched  closely: 

B     Olei  terebinthinae    3  j 

Mucilaginis    acacise    §  ij 

Misturae  amygdalae    q.  s.  ad  §  vj 

Misce. 

Sig.:    Tablespoonful   two  or  three   times  daily. 


CHRONIC    BRONCHITIS.  171 

Creosote  is  excellent,  especially  combined  with 
codliver  oil. 

Where  the  bronchitis  is  of  rheumatic  or  gouty 
origin,  the  following  may  be  used: 

IJ     Sodii  salicylatis    3  vj 

Glycerini     3  iv 

Vini  colcliici    3  vj 

Syrupi  scillse  compositsE   5  iss 

Tincturse  opii  camplioratae    5  ij 

Misce  et  fiat  misturte. 

Sig. :   Teaspoonful  with  water  every  two  or  three  hours. 

Benzoic  acid  or  its  salts  are  useful. 

IJ     Terpinolis     3  j 

Sodii  benzoatis    S  j 

Extract!  glycyrrhizse   gr.  xx 

Sacchari  lactis    gr.  xxx 

Misce  et  filant  capsulse  No.  XXX. 

Sig.:   2  to  4  capsules  three  times  daily. 

Or: 

R.     Terebeni    gr.  xcvj 

Eucalyptolis     TTL  xc 

Syrupi   yerba   santa    q.  s.  ad  o  ij 

Misce. 

Sig. :   Teaspoonful  every  two  or  three  hours. 

Inhalations  of  antiseptics  and  deodorants  often 
act  very  beneficially. 

I^     Thymol    gr.  xv 

Eucalyptolis     TTt  xx 

Creosoti    { Beech  wood )     3  i  j 

Olei  pini  sylvestris  3  iv 

Olei   gaultherise    3  j 

Misce. 

Sig.:   Inhale  from  small  cup  while  being  warmed  over   a 
spirit  lamp.     (Merck.) 


172        DISEASES   OF   THE    LUNGS   AND    PLEUR.E. 

Or: 

IJ     Mentholis    gr.  xx 

Eucalypti     TTl,  xx 

Chloroformi     q.  s.  ad  3  iv 

Misce. 

Sig. :   Inhale  5  to   10  drops  from  palm  of  the  hand  three 
times  daily. 

Or: 

I^     Olei   eucalypti    Til  xxx 

Mentholis gr.  x 

Thymol    gr.  v 

Guaiacolis    crystallisati    gr.  vi j 

Alcoholis     q.  s.  dissolve 

Tincturse  benzoini  compositse  q.  s.  ad  §  ij 

Misce  et  fiat  misturse. 

Sig.:    Float  teaspoonful  on  pint  of  boiling  water  in   can 
and  inhale  the  steam  two  times  daily. 

Where  the  pulse  is  weak  and  stimulants  are 
needed,  the  elixir  of  iron,  quinin,  and  strychnin,  tea- 
spoonful  three  times  daily  after  meals,  is  excellent. 
In  emphysema,  strychnin  is  the  remedy  par  excel- 
lence. 

If  the  bronchitis  is  due  to  engorgement  from  car- 
diac disease,  digitalis  should  be  used  as  outlined 
under  treatment  of  valvular  disease  of  the  heart. 

Nephritis,  when  present  as  the  cause,  should  be 
treated  rather  than  the  bronchitis. 

Bronchiectasis. 

Remember  that  it  very  frequently  follows  attacks 
of  grippe. 

Remember  that  the  sputum  is  expectorated  in 
large  masses,  is  greenish-yellow,  and  has  a  bad  odor. 


BRONCHIECTASIS.  173 

Remember  that  over  the  cavities  formed  by  the 
dilatation  will  be  found  tympany,  the  cracked-pot 
sound,  bronchial  breath  sounds  with  rales,  and 
bronchophony.     The  vocal  fremitus  is  increased. 

Remember  that  when  the  cavity  fills  with  secre- 
tions, all  the  above  signs  will  disappear,  but  will 
suddenly  reappear  following  a  coughing  spell  and 
expectoration. 

Remember  that  cavity  with  signs  of  catarrh  in 
both  apices,  and  sputum  brought  up  frequently  in 
small  quantities  rather  than  occasionally  by  mouth- 
fuls,  indicate  tuberculosis  of  the  lungs. 

Remember  that  the  presence  of  the  tubercle  bacilli 
in  the  sputum  is  positive  sign  of  phthisis  pulmonalis. 

Remember  that  the  cough  is  absent  during  the 
day  in  bronchiectasis  and  occurs  in  paroxysms  night 
and  morning  on  change  of  position. 

Remember  cerebral  abscess  is  a  very  frequent  com- 
plication in  bronchiectasis. 

Treatmext. 

Internal  antiseptics  that  are  excreted  through  the 
bronchial  mucosa  are  indicated.  Oil  of  turpentine 
is  very  effective  given  in  10  to  15  drops  in  milk 
three  or  four  times  daily,  or  it  may  be  given  in 
capsules,  as: 

IJ     Olei   terebinthinse   rectificati    TT],  x  vel  TTL  xx 

Dentur  tales  capsulae  mollis  No.  L. 

Sig. :   2  or  3  capsules  daily  with  glass  of  milk. 

Myrtol,  an  oily  liquid  obtained  from  the  leaves 


174        DISEASES    OF    THE    LUNGS    AND    PLEURiE. 

of  the  coininon  myrtle,  is  excellent,  acting  both  as 
antiseptic  and  deodorant  to  bronchial  secretions. 

B     Myrtolis TT],  ij 

Fiat  dosis  No.  I.     Dentur  tales  capsulae  mollis  No.  L. 
Sig. :  3  to  6  capsules  daily. 

Eucalyptus,  either  as  a  liquid  or  the  oil,  is  good. 

B     Tincturse    eucalypti    3  ss-3  j 

Syrupi  aurantii .  3  iv 

Aquae  destillatse   q.  s.  ad  ^  vj 

Misce  et  fiat  misturas. 

Sig.:   Tablespoonful  every  two  hours. 

Or: 

R.     Olei  eucalypti    TT],  iss-TTt  iv 

Fiat  capsula  No.  I.     Dentur  tales  mollis  capsulae  No.  L. 
Sig.:   Capsule  five  or  six  times  daily. 

Remember  that  sedatives  should  not  be  given,  lest 
gangrene  develop,  but  ipecac  may  be  used  to  aid  in 
the  expulsion  of  the  putrid  secretions.  The  creosote 
vapor  bath  is  very  satisfactory  in  many  cases.  The 
patient's  eyes  must  be  protected  by  well-fitting 
goggles  and  the  nostrils  stuffed  with  cotton-wool. 
It  should  be  given  in  a  small  room.  A  dram  of 
creosote  is  poured  upon  water  in  a  saucer  and  vapor- 
ized by  placing  over  a  spirit  lamp.  The  bath  should 
be  given  on  alternate  days  for  about  fifteen  minutes, 
and,  if  well  borne,  gradually  lengthen  the  time  to 
one  hour  and  give  daily. 

Surgical  interference  is  indicated  when  a  single 
large  cavity  can  be  definitely  localized.  It  should 
be  opened  externally  and  drained. 


BRONCHIAL   ASTHMA.  '      175 

Bronchial  Asthma. 

Remember  that  in  some  cases  there  are  premoni- 
tory symptoms,  such  as  chilliness,  a  sense  of  tight- 
ness in  the  chest,  indigestion,  and  the  passage  of  a 
large  quantity  of  urine. 

Remember  that  many  of  the  attacks  occur  in  the 
night  and  the  patient  awakes  with  a  sense  of  suf- 
focation. 

Remember  that  the  dyspnea  is  expiratory  and 
that  inspiration  is  short,  but  expiration  prolonged 
to  twice  the  usual  time. 

Remember  that  the  respiratory  rate  is  not  in- 
creased. 

Remember  that  the  abdominal  muscles  are  tense 
and  hard,  being  used  to  assist  in  expiration. 

Remember  that  the  percussion  sound  is  louder  and 
has  a  peculiar  note — the  "bandbox"  sound. 

Remember  that  the  vesicular  murmur  on  ausculta- 
tion is  suppressed  and  may  be  replaced  by  bronchial 
breathing. 

Remember  that  dry,  sibilant,  sonorous,  whistling 
rales  are  heard  on  expiration. 

Remember  that  the  appearance  of  the  patient  dur- 
ing a  paroxysm  is  quite  characteristic — face,  pale; 
expression,  anxious;  speech,  impossible;  later  per- 
spiration, with  cold  extremities. 

Remember  that  the  sputum  is  very  distinctive. 
Early  in  the  paroxysm  it  is  tenacious,  brought  up 
with  difficulty,  and  is  formed  into  rounded,  gelati- 
nous masses — the  pearls  of  Lsennec. 


176       'DISEASES   OF   THE    LUNGS   AND    PLEURJ5. 

Eemember  that  these  gelatinous  masses,  when  un- 
foldedj  are  spirally-arranged  molds  of  the  bron- 
chioles. 

Remember  that  these  molds  are  the  Curschmann 
spirals,  and  microscopically  are  found  to  consist  of 
filaments  of  mucin,  in  which  are  entangled  leuco- 
cytes and  the  majority  of  them  eosinophils. 

Remember  that  Charcot's  crystals  are  found  very 
frequently  and  often  called  asthma  crystals.  They 
are  pointed,  octohedral  crystals. 

Remember  that  eosinophils  of  the  blood  are 
greatly  increased. 

Remember  that  in  spasm  of  the  glottis  the  dyspnea 
is  inspiratory,  and  there  are  extensive  excursions 
of  the  larynx  during  respiration  and  inspiratory  re- 
traction of  the  epigastrium. 

Remember  that  the  tympany  from  the  acute  infla- 
tion of  the  lungs  is  absent  in  spasm  of  the  glottis. 

Remember  that  in  bronchial  asthma  the  dyspnea 
is  paroxysmal  and  in  the  interval  respiration  is  nor- 
mal, while  in  emphysema  of  the  lungs  the  respira- 
tory symptoms  are  continuous. 

Remember  that  the  dyspnea  of  cardiac  asthma  is 
both  inspiratory  and  expiratory,  and  the  abnormal 
pulmonic  sounds  of  bronchial  asthma  are  absent  in 
cardiac  asthma. 

Treatment. 

The  treatment  divides  itself  into  the  treatment  of 
an  attack  and  treatment  in  the  interval.  Do  not  pre- 
vent the  patient  from  employing  any  means  which 


BRONCHIAL   ASTHMA.  177 

has  already  proved  useful  in  his  case  in  preventing 
or  stopping  attacks. 

Treatment  of  an  Attack. 

A  hypodermic  of  morphinse  sulphatis  gr.  /4-gr.  Vi, 
with  atropinae  sulphatis  gr.  %o  and  spiritus  glyc- 
erylis  nitratis  iTt  ij,  will  give  the  most  prompt  and 
reliable  results. 

Adrenalin  solution  (1:1000)  ttl  v-Tix  x  hypoder- 
matically  will  usually  give  prompt  relief,  but  it 
should  not  be  used  in  arteriosclerosis. 

Chloral  hydrate  may  be  used,  but  the  dose  re- 
quired (gr.  xxx-gr.  xl)  is  entirely  too  large  for 
safety. 

Tobacco  smoke,  hot  coffee,  or  fresh  air  often  gives 
relief. 

Chloroform  inhalations  usually  act  promptly,  es- 
pecially in  children. 

Pilocarpin  gr.  %  hypodermatically,  by  producing 
profuse  perspiration,  will  often  relax  the  bronchial 
mucosa. 

Pearls  of  nitrite  of  amyl  may  be  broken  on  a  hand- 
kerchief and  inhaled;  2  to  5  drops  may  be  used. 

Fluidextract  of  grindelia  ni  x-ttl  xx  is  often  excel- 
lent, especially  if  bronchitis  be  present. 

The  leaves  of  stramonium,  belladonna,  or  hyos- 
cyamus  may  be  made  into  cigarettes  and  smoked,  or 
they  may  be  powdered  and  burned  in  a  saucer  and 
the  smoke  inhaled.  Saltpeter  may  be  mixed  with 
the  leaves  in  a  saucer,  or  the  cigarettes  may  be 


178        DISEASES    OF    THE    LUNGS   AND    PLEUK^. 

soaked  in  a  solution  of  saltpeter  and  dried,  and  then 
smoked,  as: 

IJ     Pulveris  stramonii, 

Pulveris  belladonnse, 

Pulveris  hyoscyaminae, 

Pulveris  potassii  nitratis    aa  5  j 

Misce. 

Sig. :    Burn  half   a   teaspoonful   in   a   shovel    and    inhale 
fumes. 

Interval  Treatment. 

If  tlie  cause  can  be  detected,  it  should  of  course  be 
removed  or  corrected. 

lodids  and  belladonna  will  give  better  results 
than  any  other  form  of  medication. 

IJ     Potassii   iodidi    gr.  xl 

Tincturae  belladonnse    TIX  xl 

Spiritus  setheris  corapositEe    3  ij 

Aquae    q.  s.  ad  B  ij 

Misce. 

Sig. :  Teaspoonful  three  or  four  times  daily. 


Or: 


IJ     Liquoris  potassii  arsenitis    3  j 

Tincturae  belladonnae    3  j 

Potassii   iodidi    3  ij 

Fluidextracti  grindeliae  (U.  S.  P.)  .  .3  vj 
Aquae    q.  s.  ad  §  iv 

Misce. 

Sig.:  Teaspoonful  after  meals. 

Or: 

IJ     Potassii   iodidi    3  iiss-3  iv 

Tincturae  belladonna   3  j-3  ij 

Essentiae  pepsini  (Fairchild)  q.  s.  ad  5  iij 

Misce. 

Sig. :   Teaspoonful  every  three  hours  until    relief    is    per- 
manent. 


BRONCHIAL  ASTHMA EDEMA  OF  LUNGS.    179 


Or: 


IJ     Potassii   iodidi    3  ij 

Liquoris  potassii  arsenitis   3  j 

Vini    ipecacuanhae    3  i  j 

Tincturae   hyoscyaminse    3  iv 

Aquae  chlorof ormi    q.  s.  ad  5  viij 

Misce. 

Sig. :  Tablespoonful  after  meals. 

Iron  should  be  administered  if  anemia  be  present. 

J^     Quininae   hydrocliloridi    gr.  xxv 

Ferri  carbonatis    gr.  xxx 

Arseni  trioxidi    gr.  ^4 

Misce  et  fiant  capsulae  No.  XV. 

Sig.:   Capsule  after  meals. 

Diet  of  asthmatics  should  be  simple,  as  an  indis- 
cretion will  often  cause  an  attack. 

The  bowels  must  be  kept  regular,  either  by  the 
use  of  mineral  waters  or  saline  cathartics. 

An  equable  climate  is  to  be  recommended  if  the 
patient  is  able  to  afford  it. 

If  there  is  emphysema,  high  altitudes  are  not  well 
borne  and  should  not  be  recommended. 

Where  chronic  bronchitis  is  present,  a  warm,  dry 
atmosphere  is  best.  In  such  a  climate  the  open  air 
treatment,  as  used  in  pulmonary  tuberculosis,  will 
give  best  results. 

Edema  of  the  Lungs. 

Remember  that,  in  rare  instances,  the  exudation  of 
fluid  into  the  alveoli  may  be  so  rapid  and  abundant 
that  dullness,  increased  pectoral  fremitus,  bronchial 
breathing,  and  the  signs  of  complete  absence  of  air 
from  the  alveoli  occur. 


180        DISEASES    OF   THE    LUNGS   AND    PLEURA. 

Remember  that  there  are  two  forms — the  inflam- 
matory and  that  due  to  engorgement. 

Remember  that  the  onset  is  usually  sudden,  with 
rapid  breathing,  a  feeling  of  oppression,  and  pain 
in  the  chest. 

Remember  that  dyspnea  and  cyanosis  occur — the 
signs  of  the  accumulation  of  carbon  dioxid  in  the 
blood. 

Remember  that  rales,  moist  and  bubbling,  may  be 
heard. 

Remember  that  the  sputum  is  characteristic,  and 
is  copious,  foamy,  and  serous  (resembling  soap 
suds),  or  it  may  be  blood-tinged. 

Remember  that  the  second  pulmonic  sound  of  the 
heart  is  accentuated,  and  in  that  form  due  to  en- 
gorgement the  pulse  is  small. 

Remember  that  it  may  prove  fatal  in  a  few  hours, 
or  it  may  pass  off  and  the  patient  have  recurrence 
of  the  attack. 

Remember  that  acute  edema  of  the  lung  may  fol- 
low aspiration  of  the  thorax  for  the  removal  of  fluid. 

Treatment. 

Bleeding  is  the  first  and  most  beneficial  procedure 
to  be  adopted;  6  to  10  ounces  of  blood  should  be 
taken. 

Cardiac  stimulants,  those  acting  quickest,  is  the 
next  step  in  treatment.  Camphor,  ether,  or  strophan- 
thus  are  to  be  given  hypodermatically. 

Morphin  and  atropin  are  practically  a  specific  in 


EDEMA  OF  LUNGS LOBAR  PNEUMONIA.    181 

many  cases.     Atropin  is  especially  indicated  and 
should  be  given  in  a  rather  large  dose. 
Ergot  is  useful,  and  may  be  exhibited  as  follows: 

IJ.     Fluidextracti   ergotag    TTL  xlv 

Spiritus  setheris    3  j-3  iss 

Aquae  cinnamomi q.  s.  ad  5  v 

Misce. 

Sig.:  Tablespoonful  every  half  to  one  hour. 

Purging  with  croton  oil  iu  ii-""!  iij  on  the  tongue 
will  often  assist  in  checking  the  transudation  of 
fluid.  Elaterium  may  be  used.  These  drastic  purga- 
tives should  not  be  used  in  cardiac  disease,  and  very 
cautiously  if  nephritis  be  the  cause  of  the  edema. 

Dry  cupping  and  the  mustard  draft  are  useful 

adjuncts. 

Lobar  Pneumonia. 

Remember  that  in  no  other  infectious  disease  is 
a  chill  so  constant  or  so  severe.  It  usually  begins 
suddenly,  without  any  premonitory  symptoms. 

Remember  that  the  pain  in  the  side  follows  close 
after  the  chill,  and  is  severe,  especially  when  the 
patient  coughs. 

Remember  that  the  hurried,  shallow  breathing  is 
often  accompanied  by  a  short  expiratory  grunt. 

Remember  that  the  fever  rises  rapidly,  and 
reaches  the  fastigium  in  twelve  hours  or  less. 

Remember  that  by  the  end  of  the  second  day  there 
is  the  rusty  sputum — scanty,  viscid,  and  blood- 
stained. 

Remember  that  cyanosis  and  dyspnea  occur  early, 
due  to  pulmonary  obstruction. 


182        DISEASES    OF   THE    LUNGS   AND    PLEUK-^. 

Remember  tliat  the  respiration  rate  is  greatly  in- 
creased, reaching  40  to  60  per  minute. 

Remember  that  the  pulse  is  strong  and  full  at  the 
beginning,  but  later  becomes  feeble  and  small,  run- 
ning 90  to  120  per  minute. 

Remember  that  a  pulse  of  140  to  150  is  an  un- 
favorable prognostic  omen. 

Remember  that  the  pain  may  be  referred  to  the 
abdomen  instead  of  the  chest — very  common  with 
children. 

Remember  that  any  abdominal  pain  of  sharp,  lan- 
cinating character  calls  for  examination  of  the  chest 
for  pneumonia. 

Remember  that  a  red  spot  on  the  cheek  of  the 
affected  side  is  very  frequently  seen  in  pneumonia, 
and  that  herpes  at  the  junction  of  the  mucous  mem- 
brane and  the  skin  of  the  lips  occurs  in  nearly  half 
the  cases. 

Remember  that  inspection  shows  a  decided  differ- 
ence in  the  expansion  of  the  two  sides. 

Remember  that  marked  movement  of  the  chest- 
wall  over  the  affected  lung  may  be  observed,  due  to 
the  pulsation  of  the  consolidated  lung. 

Remember  that  pleural  friction  may  be  better  felt 
than  heard,  and  vocal  fremitus  on  palpation  is 
greatly  increased  in  comparison  with  the  corre- 
sponding point  on  the  healthy  side. 

Always  ask  the  patient  to  cough,  and  thus  clear 
the  larger  tubes,  before  palpation. 

Remember    that    percussion    reveals    pathologic 


LOBAR    PIS^EUMOKTA.  183 

changes — viz.,  Skoda's  resonance — found  in  the 
stage  of  engorgement.  The  note  is  high-pitched 
and  has  a  somewhat  tympanitic  quality.  This  may 
also  be  obtained  over  the  lung  tissue  bordering 
a  consolidated  area.  In  the  stage  of  hepatization 
the  note  is  dull  or  flat. 

Remember  that  you  never  find  the  vrooden  flat- 
ness of  effusion;  neither  is  the  sense  of  resistance  so 
great. 

Remember  that  on  auscultation,  early  in  the  dis- 
ease, is  heard  a  fine,  crepitant  rale — a  series  of 
minute  cracklings  heard  close  to  the  ear. 

Remember  that  the  crepitant  rale  is  heard  at  the 
end  of  inspiration  and  may  not  be  heard  until  a  full 
breath  be  drawn. 

Remember  that  tubular  breathing  is  heard  over 
the  dull  area  of  consolidation.  It  is  heard  first  with 
expiration,  but  later  it  becomes  more  intense,  of  high 
pitch,  perfectly  dry,  and  of  equal  length  with  in- 
spiration and  expiration. 

Remember  that  the  second  heart  sound  over  the 
pulmonary  artery  is  accentuated. 

Remember  that  increased  cardiac  dullness  to  the 
right  of  the  sternum  and  the  pulmonary  second 
sound  becoming  less  distinct  indicate  beginning  of 
heart  failure. 

Remember  that  the  soft,  easily  compressed  pulse, 
with  a  gray,  ashy  face,  feet  and  hands  cold,  clammy 
perspiration,  signifies  a  profound  toxemia. 

Remember  that  there  is  a  diminution  of  the  chlo- 


184        DISEASES   OF    THE    LUNGS   AND    PLEUEiE. 

rids  in  the  urine,  and  this  does  not  occur  in  empy- 
ema or  pleurisy  with  effusion. 

Remember  that  the  continuous  absence  of  leuco- 
cytosis  is  to  be  regarded  as  an  unfavorable  sign. 

Remember  that  in  the  old  and  debilitated  the  on- 
set is  insidious,  and  the  symptoms  are  ill-defined 
and  latent. 

Remember  that  rapid  pulse,  rapid  respiration,  and 
fever  call  for  a  careful  examination  of  the  chest. 

Remember  that  in  cerebrospinal  meningitis  there 
are  muscular  rigidity  and  retraction  of  the  head. 
Kernig's  sign  is  present  and  lumbar  puncture  gives 
a  turbid  spinal  fluid. 

Remember  that  in  a  hemorrhagic  infarct  the  blood 
is  less  thoroughly  mixed  with  the  sputum,  absence 
of  fever,  circumscribed  dullness,  and  the  presence 
of  a  condition  capable  of  giving  rise  to  embolism. 

Remember  that  in  edema  the  sputum  is  frothy  and 
thin,  and  dullness,  if  present,  is  found  over  the  base 
of  both  lungs  posteriorly. 

Remember  that  broncho-pneumonia  usually  fol- 
lows some  other  condition,  as  measles  or  other  acute 
infectious  diseases;  comes  on  gradually  without  a 
chill,  runs  an  indefinite  course  and  terminates  by 
lysis. 

Remember  that  lobar  pneumonia  sets  in  abruptly 
with  a  chill  in  a  person  of  previous  good  health,  runs 
an  acute  course  and  terminates  by  crisis. 

Remember  that  in  pleurisy  with  effusion  the  on- 
set is  with  chilliness,  but  no  distinct  chill;  moderate 


LOBAR    PlSTEUMOlSriA.  185 

fever;  the  percussion  note  is  flat,  with  a  peculiar 
sense  of  inelasticity;  vocal  fremitus  feeble  or  abol- 
ished, and  bronchial  breathing  distant  and  faint; 
the  S-shaped  line  of  dullness,  with  a  change  on  a 
change  of  position  of  the  patient;  finally  the  inser- 
tion of  the  aspirator  needle  and  the  withdrawal  of 
fluid  settles  the  diagnosis. 

Remember  that  in  many  cases  acute  tuberculo- 
pneumonic  phthisis  can  not  be  differentiated  until 
softening  occurs  and  elastic  fibers  and  tubercle  ba- 
cilli appear  in  the  sputum.  The  important  points 
are  heredity,  previous  cough,  and  loss  of  weight;  ir- 
regular fever,  corresponding  to  the  remittent  type 
rather  than  the  continuous;  circumscribed  areas  of 
high-pitched,  ringing,  coarse,  crepitant  rales,  per- 
sisting with  little  change,  and  a  mucopurulent, 
greenish  sputum. 

Treatment. 

Remember  that  in  the  treatment  of  lobar  pneu- 
monia the  conservation  of  the  heart  is  paramount. 

The  patient  should  be  isolated,  the  room  should 
be  well  ventilated,  and  the  temperature  of  65°  to 
75°  F. 

The  fresh  air  treatment  lessens  cough,  improves 
appetite,  lowers  temperature,  and  diminishes  pulse 
and  respiration  rate. 

Rest  in  bed,  with  as  little  disturbance  as  possible, 
conserves  the  vital  forces  and  relieves  the  heart  of 
unnecessary  work. 


186         DISEASES    OF    THE    LUNGS    AND    PLEURA. 

The  diet  should  be  nutritious  and  easily  digested. 
Milk  should  constitute  the  larger  portion.  To  this 
may  be  added  eggs,  meat  broths,  jellies,  and  gruels. 

Food  should  be  given  at  stated,  short  intervals 
in  definite  amounts.  Plenty  of  pure  water  should 
be  given  throughout  the  attack,  unless  evidences  of 
cardiac  failure  develop,  when  it  should  be  restricted. 

Calomel,  either  in  fractional  doses  or  in  one  dose 
of  2  to  3  grains,  followed  by  one  of  the  salines,  is 
indicated  in  the  beginning;  subsequently  the  bowels 
should  be  kept  free  by  the  use  of  the  salines. 

The  skin  should  be  kept  active  by  sponging  and 
the  kidneys  by  use  of  water. 

Pleuritic  pain  at  the  onset  may  be  relieved,  in 
some  cases,  by  hot  or  cold  applications.  Strapping 
of  the  chest  on  the  affected  side  with  adhesive  strips 
gives  great  relief.  Morphin  gr.  ^-gr.  %,  with  atro- 
pin  gr.  Yioo,  will  be  required  to  relieve  the  severe 
pain. 

Tympanites,  when  it  occurs,  can  often  be  relieved 
by  a  careful  revision  of  the  diet.  A  colon  tube  may 
be  used  to  draw  off  the  gas,  or  hot  turpentine  stupes. 
Some  of  the  cases  are  due  to  paresis  of  the  muscu- 
lar coat  of  the  intestines,  when  a  hypodermic  of 
strychnin  nitrate  gr.  %o  three  or  four  times  in 
twenty-four  hours  should  be  administered.  At  times 
a  hypodermic  of  eserin  will  give  prompt  relief.  In 
severe  cases  a  hypodermic  of  aseptic  ergot  intra- 
muscularly is  of  the  greatest  value. 

Baths  should  be  used.    Tepid  baths  or  sponging 


LOBAR    PNEUMONIA.  187 

is  best.  The  cold  bath  should  not  be  used  unless  the 
temperature  is  very  high. 

Venesection  is  life-saving  in  many  sthenic  cases 
with  signs  of  engorgement  and  failing  right  heart. 
The  withdrawal  of  20  to  30  ounces  of  blood  will  re- 
lieve the  congestion  and  tide  the  patient  over  his 
critical  period. 

Expectorants  are  not  to  be  given  indiscriminately, 
because  they  derange  digestion. 

The  dry,  irritating  cough  is  best  relieved  by  co- 
dein,  and  ammonium  chloridi  will  render  the  sputum 
less  tenacious.  They  are  best  given  in  an  acid  mix- 
ture, as: 

I^     Codeinae   sulphatis    gr.  ii j-gr.  v 

Ammonii  chloridi   3  iss-3  ij 

Syrupi  acidi  citrici    o  iss 

Aquae     q.  s.  ad  B  ii j 

Misce. 

Sig. :  Teaspoonful  every  two,  three,  or  four  hours  as  needed. 

If  the  cough  is  not  troublesome,  omit  the  codein. 
Sleeplessness  is  usually  controlled  by  sponging  or 
bath  and  fresh  air.  If  the  patient  is  still  unable  to 
sleep,  some  hypnotic  should  be  given.  If  the  circu- 
lation is  good,  trional  or  sulphonal  gr.  x  in  hot  milk 
or  whisky  may  be  given.  Veronal  gr.  v  is  safer  and 
very  efficacious. 

Morphin  in  small  doses  should  be  given  where  the 
heart  is  weak.  When  the  heart  begins  to  fail, 
strychnin  should  be  used,  but  it  should  not  be  pushed 
except  in  emergency.  Given  hypodermatically,  gr. 
Yso  every  six  hours,  is  best. 


188        DISEASES    OF    THE    LUNGS    A^s^D    PLEUE^. 

If  there  is  profuse  cold  sweating,  with  cardiac 
failure,  atropin  sulphate  gr.  M.20,  repeated  every  six 
hours,  is  indicated. 

Whisky  or  brandy  should  be  given  to  alcoholics, 
and  may  be  used  when  cardiac  stimulants  are  indi- 
cated.   Half  an  ounce  every  three  hours  until  effect. 

Aromatic  spirits  of  ammonia  and  spirits  of  min- 
dererus  are  excellent  where  mild  stimulants  are 
needed. 

Digitalis  is  highly  recommended  by  many  in  se- 
vere cases.  The  infusion  is  probably  the  best,  but 
the  tincture,  in  large  doses  (nx  v-ttl  xv)  every  three 
hours,  is  used. 

I^     Potassii    acetatis    3  j 

Jnfusi  digitalis    (leaves)     5  iij 

Misce. 

Sig. :    Tablespoonful   every  two   or  three  hours,  depending 
upon  the  severity  of  the  case. 

Or: 

E     Spiritus  ammonii  aromatici ^  ss 

Fluidextracti   digitalis    3  iiss 

Glycerini    q.  s.  ad  §  iv 

Llisce  et  fiat  misturse. 

Sig.:   Teaspoonful  every  three  or  four  hours,  or  oftener  if 
needed. 

Quinin  is  very  generally  given  in  pneumonia. 
Yeo  makes  very  decided  claims  for  it  given  in  an 
effervescent  form — in  gr.  j-gr.  iij  every  three  hours. 
His  method  of  prescribing  it  is  as  follows: 

IJ     Quininse    sulphatis    gr.  j-gr.  iij 

Acidi   citrici    gr.  x-gr.  xv 

Sacchari  lactis    gr.  x 

Misce  et  fiat  pulvere  No.  I. 


LOBAE    PNEUMONIA.  189 

This  powder  is  dissolved  in  a  little  water  and 
added  to  the  following  draught : 

IJ.     Potassii  bicarbonatis   gr.  x-gr.  xv 

Ammonii   carbonatis    gr.  iij-gr.  v 

Syrupi  aurantii    3  j 

Aquae    q.  s.  ad  §  j 

Misee  et  fiat  haustus.     This  dose  to  be  given  every  two  or 
three  hours. 

The  fact  that  quinin  in  small  doses  has  been 
shown  to  increase  leucocytosis  probably  explains  its 
beneficial  action.  Never  give  large  doses,  and  best 
not  given  in  consolidation. 

Aconite  and  veratrum  are  often  used  in  the  early 
stage  or  that  of  engorgement  with  the  idea  of  jugu- 
lating the  disease.  They  are  best  given  in  small  and 
oft-repeated  doses,  and  the  alkaloid  can  be  used  to 
better  advantage.  Neither  drug  should  be  used  after 
the  congestion  is  succeeded  by  consolidation. 

Creosote,  or,  better,  creosotal  (the  carbonate),  is 
highly  extolled.  It  is  taken  into  the  blood  and  ex- 
creted through  the  lungs,  and  thus  its  germicidal 
action  is  obtained.  It  is  given  in  10-minim  doses  in 
capsules  or  in  an  emulsion. 

At  the  crisis  the  collapse  following  is  best  over- 
come by  hypodermic  of  atropin. 

Nitroglycerin  is  especially  indicated  when  the 
urine  is  scanty  and  contains  more  than  a  trace  of 
albumin. 

Notwithstanding  its  high  recommendations,  hypo- 
dermoclysis  is  rarely  indicated  in  pneumonia,  and 
the  very  excellent  contraindication  exists  of  too 
much  fluid  for  a  tiring  heart. 


190        DISEASES    OF    THE    LUNGS   AND    PLEURA, 

In  convalescence  great  care  should  be  exercised 
to  protect  a  heart  that  has  been  overworked,  that 
dilatation  may  not  occur.  A  return  to  a  full  diet 
should  be  slow,  and  the  patient  kept  at  rest  for  two 
months  after  his  apparent  recovery. 

Broncho-Pneumonia  (Lobular  Pneumonia). 

Remember  that  this  occurs  most  frequently  at  the 
extremes  of  life,  and  that  it  is  a  terminal  event  in 
many  chronic  conditions. 

Remember  the  frequency  with  which  it  follows 
the  contagious  diseases  of  childhood. 

Remember  that  chronic  Bright 's  disease  in  the 
aged  is  often  complicated  by  broncho-pneumonia. 

Remember  that  the  tubercle  bacilli  often  produce 
a  fatal  broncho-pneumonia. 

Remember  that  the  disease  is  almost  always 
bilateral,  while  lobar  pneumonia  is  almost  always 
unilateral  and  occurs  in  adults. 

Remember  that  if  in  convalescence  from  measles 
or  in  pertussis  a  child  has  an  accession  of  fever,  with 
cough,  rapid  pulse,  and  rapid  breathing,  and  on  aus- 
cultation fine  rales  be  heard,  a  diagnosis  of  broncho- 
pneumonia should  be  made. 

Remember  that  dyspnea  is  a  prominent  symptom, 
and  the  deficiency  of  air  is  shown  by  the  rapid  respir- 
atory rate. 

Remember  that  cyanosis  develops  later,  due  to  ac- 
cumulation of  carbon  dioxid. 

Remember  that  the  fine,  subcrepitant  rales  are 


BEONCHO-PNEUMONIA.  191 

heard  at  first,  and  later  lubular  breathing  over  the 
affected  areas. 

Remember  that  percussion  usually  shows  a  circum- 
scribed relative  dullness,  which  is  usually  bilateral, 
radiating  along  the  spinal  column. 

Remember  that  miliary  tuberculosis  is  usually  lo- 
calized in  the  apices  of  the  lungs,  and  the  presence 
of  choroidal  tubercles  in  the  eye  facilitates  the  diag- 
nosis. 

Treatment. 

The  proper  care  of  a  child  convalescing  from 
measles,  diphtheria,  and  whooping-cough  will  pre- 
vent such  a  serious  complication  as  broncho-pneu- 
monia. 

Keep  the  room  at  an  even  temperature  and  the  air 
moist  with  vapor. 

Calomel  gr.  Vio-gr.  Yq  should  be  given  hourly  until 
a  good  movement  from  the  bowels  is  obtained.  The 
bowels  must  be  kept  open  during  the  illness  with 
salines. 

Fever,  if  high,  use  water,  either  as  cool  sponging, 
pack,  and,  in  severe  cases,  the  bath.  Keep  ice  cap 
to  the  head. 

Aconite  or  veratrum,  as  the  tincture,  may  be  used 
cautiously  to  lower  temperature.  It  is  best  given 
alone  in  drop  doses  every  half  to  one  hour  in  water 
until  effect,  then  every  one  or  two  hours.  A  good 
combination  is  the  following,  and  it  possesses  the 
advantage  of  having  a  stimulant  in  combination : 


192        DISEASES    OF    THE    LUNGS   AISTD    PLEIIRiE. 

IJ     Aconitin  amorphous, 

Veratrini   aa  gr.  i,^q 

Digitalini     •  .  •  ., gr.  i^ 

Aquae     q.  s.  ad  5  ij 

Misce  et  fiat  solutio. 

Sig. :  Teaspoonful  every  half  hour  for  5  doses,  then  hourly. 

A  good  saline  fever  mixture : 

IJ     Potassii  citratis    gr.  xxx-gr.  1 

Liquoris   ammonii   acetatis    B  j 

Spiritus  ammonii  aromatici   3  iv 

Syrupi   aurantii    3  vj 

Aquse    q.  s.  ad  §  ij 

Misce  et  fiat  solutio. 

Sig.:  Teaspoonful  every  two  hours. 

To  this  may  be  added  sodium  bromid  if  the  child 
is  nervous. 

Cough  is  best  relieved  with  codein. 

IJ     Codeinse  phosphatis    gr.  ij-gr.  iv 

Ammonii   carbonatis    gr.  xxx 

Tincturse   hyoscyaminse    5  iv 

Syrupi  pruni  virginianse 3  vj 

Aquae  camphorae q.  s.  ad  §  i j 

Misce. 

Sig.:  Teaspoonful  every  two  hours. 

Or: 

IJ     Ammonii   carbonatis    3  ij 

Ammonii   iodidi    3  iij 

Syrupi   glyeyrrhizse    ^  ij 

Syrupi  tolutani    §  ij 

Misce. 

Sig.:   Teaspoonful  every  two  or  three  hours. 

Or: 

IJ     Vini    antimonii     3  j 

Spiritus  aetheris  nitrosi    3  iij 

Tincturse  opii  camphoratse   3  iiss 

Liquoris   ammonii  acetatis .  .  q.  s.  ad  §  ij 

Misce. 

Sig.:    Teaspoonful  every  two  hours  for  child  three  to  five 
years. 


BRONCHO-PNEUMONIA.  193 

Brandy  should  be  given,  best  in  milk,  when  stimu- 
lants are  needed. 

Diet  should  be  light  and  nutritious,  such  as  milk, 
broths,  and  eggs  in  the  form  of  albumen  water. 
Plenty  of  cold  water  should  be  given.  A  cup  of  cold 
water  should  be  kept  by  the  bed,  and  the  child  en- 
couraged to  drink  freely. 

If  the  pulse  shows  any  signs  of  weakening,  brandy 
should  be  given  either  in  milk  or  in  albumen  water. 

Strychnin  is  indicated  in  rapid  cardiac  failure. 
For  a  child  of  six  months  gr.  ^oo  should  be  given 
hypodermatically  every  three  or  four  hours. 

Tincture  of  belladonna  ni  j-tii  ij  every  two  or 
three  hours  is  an  excellent  respiratory  stimulant,  but 
atropin,  combined  with  strychnin,  is  much  better. 

Venesection  is  very  seldom  indicated  in  children 
or  the  aged. 

Remember  that  it  is  a  patient  you  are  treating,  not 
pneumonia,  and  be  governed  accordingly. 

During  convalescence  tonics  containing  iron  are 
needed  and  of  these  none  are  better  than: 

IJ     Elixiris    ferri,    quininee    et    strycli- 
ninse  phosphatis, 
Essentia  pepsini    ( FaircMld )     ..aa^iss 
Misce. 
Sig.:  Teaspoonful  three  times  daily. 

Or: 

-    IJ     Euquinini    ( Merck )    gr.  xxxv 

Syrupi  pruni  virginianse    3  iv 

Misce  et  fiat  misturse  et  adde 

Liquoris  potassii  arsenitis TTL  xxx-TTL  xl 

Aquae  menthse  piperitse    ....  q.  s.  ad  §  i j 
Misce, 
Sig.:   Teaspoonful  three  times   daily  after  meals. 


194        DISEASES   OF   THE    LUNGS   AND    PLEUEiE. 

Chronic  Interstitial  Pneumonia. 

Remember  that  the  history  is  very  important,  as 
it  frequently  occurs  as  a  sequence  of  inhalations  of 
iron,  coal,  or  stone  dust,  and  in  the  course  of 
syphilis. 

Remember  that  the  characteristic  feature  of  this 
affection  is  atrophy  of  the  lung. 

Remember  that  inspection  shows  retraction  of  the 
thorax  on  the  affected  side,  with  approximation  of 
the  ribs,  and  the  spine  curved  toward  the  affected 
side. 

Remember  that  in  severe  cases  there  will  be  drop- 
ping of  the  shoulder  and  projection  of  the  scapula, 
together  with  reduction  or  absence  of  respiratory 
movements. 

Remember  that  in  atrophy  of  the  left  lung  the  apex 
beat  of  the  heart  is  displaced  to  the  left  and  to  a 
higher  intercostal  space,  and  the  pulsation  more  dif- 
fuse, because  of  greater  cardiac  surface  exposure. 

Remember  that  in  the  second  left  interspace  over 
the  pulmonary  artery  a  systolic  bulging  and  a  dias- 
tolic thrill  becomes  visible  and  palpable.  The  thrill 
is  due  to  the  closure  of  the  pulmonic  valves,  and 
auscultation  reveals  an  accentuation  of  the  valve 
sound. 

Remember  that  if  the  atrophy  is  at  the  apices  of 
the  lungs,  they  will  be  shrunken;  and  if  at  the  base, 
the  abdominal  organs  adjacent  to  the  diaphragm  are 
displaced  upward. 


CHKOJSriC    INTERSTITIAL    PNEUMONIA.  195 

Remember  that  examination  of  the  sputum  for  the 
tubercle  bacilli  is  the  only  definite  way  to  exclude 
tuberculosis. 

Remember  that  there  will  be  no  shortness  of  breath 
in  the  ordinary  exercise,  but  exertion,  such  as  climb- 
ing stairs,  may  cause  dyspnea. 

Remember  that  chronic  cough  is  always  found,  but 
there  may  or  may  not  be  abundant  sputum. 

Remember  that  death  from  hemorrhage  or  cardiac 
failure  may  occur. 

Remember  that  fever,  when  present,  means  tuber- 
culosis if  not  due  to  other  acute  associated  process. 

Treatment. 

The  patient  should  be  protected  from  changes  of 
temperature.  It  is  better  to  send  him  to  a  warm,  dry 
climate.  The  diet  must  be  nutritious  and  easily  di- 
gested. The  bowels  should  be  kept  regular.  The 
skin  should  be  active,  and  flannel  should  be  worn. 

For  the  severe  cough  of  the  associated  bronchitis 
the  treatment  would  be  the  same  as  that  outlined 
under  chronic  bronchitis. 

Oil  of  turpentine  gtt.  x-gtt.  xx  three  times  daily 
is  excellent. 

There  is  nothing  that  will  restore  the  elasticity  of 
the  lung.  Breathing  exercise  should  be  carried  out 
to  expand  the  pulmonary  tissue.  Violent  exercise 
should  be  interdicted  because  of  the  danger  of 
hemorrhage. 


196        DISEASES    OF    THE    LUiS'GS   AXD    PLEUE^. 

Emphysema. 

Remember  that  heredity  plays  an  important  role 
in  emphysema. 

Remember  that  bronchitis  is  a  very  common  as- 
sociate. 

Remember  that  dyspnea,  with  harsh,  wheezy  res- 
piration and  prolonged  expiration,  is  characteristic 
of  emphysema.  The  ratio  between  inspiration  and 
expiration,  which  is  normally  1  to  4,  may  be  changed 
to  4  to  1. 

Remember  that  cyanosis  of  extreme  grade  is  more 
common  in  this  than  in  other  affections. 

Remember  that  the  inspiratory  effort  is  short,  but 
expiratory  is  greatly  prolonged. 

Remember  that  the  large,  barrel-shaped  chest  and 
rounded  shoulders,  with  prominent  clavicles  and 
deej)  sternal  fossa,  are  signs  of  emphysema. 

Remember  that  the  drum-like  note  on  percussion 
is  due  to  the  distended  air  vesicles.  The  cardiac 
area  of  dullness  is  greatly  reduced  or  obliterated, 
and  the  liver  dullness  lowered  even  to  the  costal 
arch. 

Remember  that  the  breath  sounds  are  feeble  and 
soft  in  character. 

Remember  that  the  obstruction  to  the  lesser  cir- 
culation causes  hypertrophy  of  the  right  heart  and 
accentuation  of  second  pulmonic  sound. 

Remember  that  cough  and  expectoration  so  often 
found  in  emphysema  are  due  to  the  accompanying 
bronchitis. 


emphysema pulmonary  gaxgrexe.   197 

Treatment. 

The  obstruction  in  the  lesser  circulation  will  cause 
digestive  disturbances ;  hence  the  diet  should  be  nu- 
tritious, easily  digested,  and  taken  in  small  amounts, 
but  frequently. 

The  bowels  should  be  kept  open. 

Iron  and  codliver  oil  are  both  indicated,  and 
strychnin  may  be  advantageously  added. 

Strychnin  is  admirable,  and  should  be  given  in 
full  doses,  beginning  with  gr.  %o  three  times  daily 
and  increased  gradually  until  gr.  %2  are  given. 

Arsenic  is  good — Fowler 's  solution — 5  drops  three 
times  daily,  or  arsenic  trioxid  gr.  %o  naay  be  used. 

The  chronic  bronchitis  should  be  treated  as  al- 
ready outlined.  The  patient  must  be  carefully  pro- 
tected from  exposure. 

For  asthmatic  attacks  that  so  frequently  occur  a 
hypodermic  of  morphin  sulphate  gr.  %,  with  atropin 
sulphate  gr.  %2o,  repeated  every  four  to  six  hours 
if  needed,  is  excellent. 

The  main  reliance  should  be  placed  upon  plenty 
of  good  food,  protection  from  exposure,  and  the 
free  use  of  strychnin  for  a  long  period  of  time. 

Pulmonary  Gangrene. 

Remember  that  this  is  a  sequence  of  a  variety  of 
conditions  in  the  lungs — as  lobar  pneumonia  in  the 
debilitated  or  diabetic  patient,  aspiration  pneu- 
monia, embolism  of  the  pulmonary  artery,  and  it  is 
in  this  manner  that  gangrene  occurs  in  typhoid. 


198        DISEASES   OF   THE   LUNGS   AND   PLEURA. 

Remember  that  the  symptoms  of  the  preliminary 
conditions  precede  those  of  gangrene. 

Remember  that  the  sputum  is  very  characteristic, 
usually  profuse  and  fetid.  The  odor  is  cadaverous 
or  mawkishly  sweet  and  penetrating. 

Remember  that  pieces  of  lung  tissue  can  be  sepa- 
rated from  the  sputa. 

Remember  that  the  peculiar  plugs  seen  in  the 
sputum  in  bronchiectasis  are  absent. 

Remember  that  elastic  fibers  are  seen  with  the 
microscope. 

Remember  that  the  color  of  the  sputum  is  ' '  dirty- 
green,  ' '  gray,  or  brown,  depending  upon  the  amount 
of  blood  it  contains. 

Remember  that  the  fever  is  not  high,  but  the 
pulse  is  rapid,  with  great  general  prostration. 

Treatment. 

The  patient  should  be  kept  on  his  back,  to  avoid 
leakage  into  sound  bronchi. 

The  diet  should  be  nutritious,  and  the  strength  of 
the  patient  must  be  su^Dported. 

Alcoholic  stimulation  should  be  used  freely. 

Turpentine  is  excellent,  gtt.  xv-gtt.  xxx,  espe- 
cially when  there  is  a  complicating  hemorrhage. 

Carbolic  spray  may  be  used,  or  better  plan  is  to 
use  an  inhaler,  covering  the  mouth  and  nose,  and 
charged  with  a  carbolic  solution,  or  with  guaiacol 
(or  creosote),  alcohol,  and  chloroform,  equal  parts. 


PULMONARY    TUBERCULOSIS.  199 

Creosote  may  be  given  both  as  an  antiseptic  and 
deodorant. 

IJ     Creosoti   (Beech-wood)    Vfl  xxx 

Alcoholis     B  j 

Glycerini     3  vj 

Aquae    q.  s.  ad  B  viij 

Misee. 

Sig. :   Tablespoonful  three  times  daily. 

When  the  gangrenous  area  can  be  located  and  the 
general  condition  of  the  patient  is  good,  surgical  in- 
tervention is  indicated. 

Pulmonary  Tuberculosis. 

Remember  that  catarrh  localized  at  the  apices  is 
very  suggestive  of  tubercular  infection. 

Remember  that  dullness  on  percussion  over  the 
apex,  with  the  patient  in  the  sitting  posture,  is  sig- 
nificant of  early  stage  of  tuberculosis. 

Remember  that  a  deviation  from  the  normal 
sounds  on  auscultation — as  jerky  respiration,  pro- 
longed expiration,  intensified  or  coarse  vesicular 
breathing,  or  distinct  respiratory  murmur — is  con- 
firmatory of  percussion  findings. 

Remember  that  evening  elevation  of  temperature 
is  present  early  in  tubercular  infection,  but  the  tem- 
perature must  be  taken  at  least  four  times  a  day. 
The  fever  may  be  of  the  remittent  or  intermittent 
type. 

Remember  that  the  gradual  loss  of  weight  and 
strength  in  young  adults  is  exceedingly  significant 
of  phthisis  pulmonalis. 


200        DISEASES    OF   THE    LUNGS    AND    PLEURA. 

Remember  tliat  ''night  sweats"  occur  more  often 
in  phthisis  than  in  any  other  condition. 

Remember  that  the  examination  of  the  sputum 
will  show,  in  time,  the  tubercle  bacilli  and  is  pathog- 
nomonic of  tuberculosis  of  the  lung,  but  they  may 
not  be  found  early  in  the  disease,  as  they  depend 
upon  the  stage  of  softening  and  breaking  down  of 
infected  lung  tissue,  with  expectoration  of  the  pus- 
like material. 

Remember  that  it  is  necessary  to  differentiate  the 
formation  of  a  cavity  and  pneumothorax,  especially 
the  sacculated  form. 

The  intercostal  spaces  over  the  cavities  are  re- 
tracted as  a  rule,  while  in  pneumothorax  the  inter- 
spaces are  bulging,  and  pectoral  fremitus  is  intensi- 
fied over  a  cavity,  but  diminished  over  pneumo- 
thorax. 

Remember  that  the  cracked-pot  sou.nd  on  percus- 
sion is  found  over  cavities,  while  distention  of  the 
thorax,  displacement  of  viscera,  especially  heart  and 
liver,  and  the  change  of  dullness  in  the  lower  por- 
tions upon  change  of  position  point  to  pneumo- 
thorax. 

Remember  that  cough  is  present  in  the  majority 
of  cases — a  dry,  hacking  cough — but  there  are  no 
characteristic  features  about  it. 

Remember  that  the  ''stomach  cough"  of  the  dys- 
peptic is  probably  of  tuberculous  origin. 

Remember  that  the  rosy  cheeks  and  bright,  spark- 
ling eyes  accompany  the  hectic  fever  of  phthisis. 


PULMONARY   TUBERCULOSIS.  201 

Remember  that  Koch 's  tuberculin  may  be  used  in 
case  of  doubt  to  determine  the  presence  of  a  tuber- 
cular infection.  The  following  method  may  be  fol- 
lowed :  for  three  days  the  temperature  is  to  be  taken 
every  three  hours  and  recorded.  On  the  fourth  day 
1  milligram  of  pure  tuberculin  is  injected  hypoder- 
matically,  and,  if  no  febrile  reaction  occurs  in  ten 
or  twelve  hours,  the  test  is  negative.  In  three  days 
twice  this  amount  is  injected  and  the  temperature 
watched  for  twelve  hours.  This  is  again  repeated 
in  three  days,  using  larger  dose  until  finally  5  milli- 
grams are  injected  at  a  dose,  when,  if  there  be  no 
fever,  headache,  and  lassitude,  the  patient  may  be 
said  to  be  free  of  tubercular  infection.  In  positive 
reaction  there  will  be  a  rise  of  2°  to  4°  F.  in  the  tem- 
perature. 

Do  not  use  tuberculin  if  a  diagnosis  is  possible 
without  it. 

Remember  that  a  rapid  pulse  and  hurried  breath- 
ing should  arouse  suspicion. 

Remember  that  hemorrhage  occurs  in  the  course 
of  the  disease,  and  may  be  the  first  intimation  that 
the  patient  is  tubercular. 

Remember  that  the  muscles  overlying  an  acute, 
active  tubercular  infection  are  rigid,  similar  to  the 
condition  of  the  right  rectus  over  an  acute  inflamed 
appendix.  This  rigidity  is  easily  detected  by  light 
palpation  of  the  intercostal  spaces. 

Remember  that  the  presence  of  pain  in  the  chest 
depends  upon  a  coexisting  pleurisy. 


202        DISEASES    OF   THE    LUNGS   AND    PLEURA. 

Always  auscultate  the  lungs  posteriorly  in  the 
interscapular  space,  as  frequently  the  earliest 
changes  of  the  respiratory  murmurs  are  heard  in 
this  region. 

Always  obtain  the  family  history,  because  hered- 
ity is  of  some  importance,  but  continued  exposure  to 
infection  is  of  great  importance  in  making  a  diag- 
nosis early. 

Treatment. 

Pulmonary  tuberculosis  is  curable,  and,  to  effect 
a  cure,  two  things  are  primarily  necessary — viz., 
nutrition  and  ventilation. 

Diet.  The  food  should  be  highly  nutritious,  and 
prepared  so  that  it  will  appeal  to  the  palate.  It 
must  of  necessity  be  a  mixed  diet  to  comply  best  with 
the  above  requirements. 

Proteids  are  of  first  importance — all  kinds  of 
meats,  and  preferably  with  some  fat. 

Eggs  are  very  nutritious,  and  taken  in  the  form 
of  egg-nog  are  very  efficacious,  but  the  patient  easily 
tires  of  eggs,  and  they  must  be  used  liberally  in  pre- 
paring other  foods,  as  salads,  soups,  dressings,  cus- 
tards, omelets,  etc. 

Vegetables — as  peas,  beans,  lentils,  and  rice — that 
contain  large  amount  of  proteid  should  be  given. 

Fats — as  butter,  cream,  oil,  bacon,  cream  cheese, 
fatty  cheese — where  the  fat  is  easily  assimilated, 
should  be  used. 

Milk  in  as  large  a  quantity  as  possible  should  be 
used — three  pints  daily  at  regular  intervals. 


pulmojstary  tuberculosis.  203 

Carbohydrates  may  and  should  form  a  good  part 
of  the  dietary. 

Ventilation,  or  fresh  air  treatment,  is  very  essen- 
tial. The  best  fresh  air  is  obtained  by  being  in  the 
open  air  day  and  night.  Sunlight  and  open  air  is 
excellent,  and  the  patient  should  be  kept  out  in  the 
sunlight.  The  bed-room  must  be  so  situated  as  to 
receive  as  much  sunlight  as  possible. 

The  patient  must  sleep  in  the  open  air.  This  may 
be  done  by  sleeping  on  a  porch,  or  with  the  bed  at 
an  open  window  so  that  the  head  will  be  in  the 
window.  There  are  a  number  of  devices  that  may 
be  attached  to  the  window  frame  and  protect  the 
patient's  body  from  exposure  in  bad  weather. 

Exercise  must  be  carefully  graded  to  preserve 
strength  and  ward  off  hemorrhage.  At  most,  it 
should  be  light,  and,  where  there  has  been  great  loss 
of  strength,  resisting  exercise  and  massage  is  better. 

Care  of  the  Mouth.  The  patient  must  be  careful 
to  cleanse  the  mouth  thoroughly  several  times  a  day 
with  some  antiseptic  solution.  He  should  also  be 
frequently  cautioned  against  swallowing  the  sputum, 
but  should  spit  it  into  a  cuspidor  containing  some 
antiseptic  solution  or  into  a  piece  of  cotton  and 
burned.  The  dishes  and  drinking  cups  of  the  pa- 
tient should  be  scalded  after  use.  In  brief,  every- 
thing must  be  done  to  prevent  the  patient  reinfecting 
himself,  so  that  he  may  escape  fresh  lesions. 

Medicinal  Therapy.  Creosote  and  codliver  oil 
probably  lead  in  therapy  of  tuberculosis.  Creosote 
may  be  used  both  internally  and  by  inhalations. 


204         DISEASES    OF   THE    LUIN^GS    AXD    PLEURA. 

B     Creosoti    ( Beecli-\vood )    gtt.  vj 

Gljcerini     3  j 

Spiritus  f rumenti   3  i j 

Misce. 

Sig. :  Dessertspoonful  diluted  with  water  every  two,  three, 
or  four  hours. 

The  dose  of  creosote  may  be  increased,  but  large 
doses  should  never  be  given,  nor  should  the  drug  be 
pushed  to  the  point  of  toleration  because  of  the  re- 
action from  the  drug.  If  the  patient  receives  any 
benefit  from  creosote,  it  is  manifested  by  increased 
appetite,  improved  nutrition,  weight  added,  expec- 
toration diminished,  pus  in  the  sputum  lessened, 
the  disappearance  of  bad  odor  from  the  sputum, 
and  associated  nontuberculous  laryngitis,  tracheitis, 
and  bronchitis  of  the  larger  tubes  cured. 

When  too  much  creosote  is  taken,  there  will  be 
loss  of  appetite,  coated  tongue,  nausea,  vomiting, 
yellow  tinge  of  the  sclera,  due  to  sluggish  liver,  and 
sugar  or  albumin  may  appear  in  the  urine.  The  pa- 
tient must  be  studied  while  taking  the  drug  to  de- 
termine whether  it  should  be  continued. 

Inhalations    of    creosote    may    be    administered 
either   alone   or  in  combination   with   other   well-- 
known  medicaments. 

I^     Creosoti    ( Beechwood ) , 
Aleoholis, 

Spiritus   chlorof ormi    aa  3  j 

Misce. 

Sig.:  10  drops  on  a  sponge  or  inhaler;  inhale  at  first  fre- 
quently for  fifteen  minutes  at  a  time  and  gradually  lengthen 
the  time  to  one  hour. 


PULMOXAEY    TrBEECULOSIS.  205 

Or: 

IJ     Creosoti    (Beectwood)    TTl,  sv 

Tincturae   benzoini   compositse    §  iij 

Misce. 

Sig. :  Teaspoonful  floated  on  cup  of  boiling  water  and  steam 
inhaled  three  or  four  times  daily.     Shake. 

Or: 

IJ     Creosoti   (Beech-wood)    TU  vij 

Olei  pini  sylvestris 3  iiss 

Tincturse  benzoini  compositae  q.  s.  ad  §  iij 

IMisce. 

Sig.:    Teaspoonful    on    boiling    water    and    inhaled    three 
or  four  times  daily.     Shake. 

Or: 

I^     Creosoti    (Beechwood)    Tll^  s 

Olei  pini  sylvestris, 

Olei  terebinthinse  aa  5  iiss 

Tincturse  benzoini  compositae  q.  s.  ad  §  iv 
Misce. 

Sig. :    Teaspoonful  on  boiling  water  and  inhaled  three  or  four 
times  daily.     Shake, 

Creosote  for  internal  use  may  be  combined  as  fol- 
lows: 

IJ.     Creosoti   (Beechwood)    TTL  j-TTj.  ij 

Olei  olivae  vel  olei  morrhuae   TTL  ij-TTL  v 

Misce  et  fiat  capsula  Xo.  I.     Dentur  tales  capsulse  mollis 
No.  L. 

Sig.:  3  to  7  capsules  three  times  daily  after  food. 

Or: 

I^     Creosoti   ( Beechwood )    3  iv 

Tincturse  gentianse  compositse   §  j 

Aleoholis     §  viij 

Vini  xerici    q.  s.  ad  0  ij 

Misce  et  fiat  solutio. 

Sig.:    2,    4:,   or   6   tablespoonfuls   three  times    daily  after 
meals  in  glass  of  milk. 


206        DISEASES    OF    THE    LUNGS   AND    PLEURA. 

Or: 

IJ     Creosoti    (Beech wood)    3ss-3j 

Olei  morrhuae    5  vj 

Acaciae, 

Aquse   menthse    piperitse    aa  q.  s. 

Misce  et  fiat  emulsio. 

Sig. :  Tablespoonful  three  to  five  times  daily. 

Guaiacol,  a  creosote  derivative,  may  be  used. 
Some  of  the  salts,  usually  the  carbonate  or  salicy- 
late, are  most  frequently  given. 

R     Guaiaeolis  carbonatis  or  salicylatis  gr.  vij 
Fiat  capsula  No.  I.     Dentur  tales  capsulse  No.  L. 
Sig.:   2  to  12  capsules  daily. 

Creosotal  is  frequently  better  borne  by  the 
stomach,  and  may  be  prescribed. 

IJ     Creosotalis    §  iij 

Sig. :  Half  teaspoonful  three  to  five  times  daily  in  milk. 

Or: 

I^     Creosotalis    3  v 

Olei  morrhuae    §  iij 

Acaciae, 

Aquae  menthae  piperitse   .  .  aa  q.  s.  ad  §  vj 
Misce  et  flat  emulsio. 
Sig.:  Tablespoonful  three  to  six  times  daily  after  meals. 

There  are  a  number  of  drugs  to  be  used  in  tuber- - 
culosis,  partly  to  keep  up  nutrition  and  partly  to 
replace  certain  substances  excreted  in  abnormally 
large  amounts. 

Arsenic  is  first.  Either  in  pill  form  or  Fowler's 
solution.  It  stimulates  nutrition  and  is  an  excellent 
general  tonic. 

Salt.     Patient  should  be  instructed  to  use  large 


PULMONARY   TUBERCULOSIS.  207 

quantity  of  table  salt  to  replace  the  abnormal  loss 
in  sputum  and  urine. 

The  phosphates  should  also  be  given.  The  best 
are  the  pharmacopeial  preparations : 

B     Syrupi  hypophosphitis    §  vj 

Or: 

R     Syrupi  calcii  lactophosphitis  5  vj 

Sig. :  To  be  given  in  teaspoonful  doses  three  times  daily. 

Anorexia  must  be  combated.  It  is  important  that 
nutrition  be  maintained.  If  high  fever  is  the  cause 
of  the  anorexia,  food  should  be  given  at  the  time  the 
temperature  is  down  and  endeavor  must  be  made  to 
reduce  the  fever.  If  pain  on  swallowing  or  cough 
interfere  with  the  taking  of  food,  narcotics  should 
be  given  before  meals.  Stomachics  may  be  used  to 
combat  anorexia,  as: 

^     Tincturae  nucis  vomicse   3  ij 

Tincturge    gentianse    compositse, 

Tincturse  cinchonse  comp.  aa  q.  s.  ad  §  iij 
Misce. 
Sig.:  Half  teaspoonful  before  meals. 

Fever.  Drugs  should  not  be  given  to  reduce  tem- 
perature until  rest  in  bed  and  fresh  air  have  failed. 
Unless  fever  is  high  and  interferes  with  nutrition 
or  causes  unpleasant  symptoms,  no  attempt  should 
be  made  to  reduce  it.  When  high,  the  diet  should 
be  liquid,  but  should  be  plentiful. 

Pyramidon  gr.  j-gr.  iij  every  three  hours  until 
effect,  or  one  single  large  dose  gr.  xv  dissolved  in 
hot  water.  This  is  the  safest  and  best  drug  to  be 
used. 


208        DISEASES    OF    THE    LUNGS   AIs'D   PLEUE^. 

Other  coal-tar  derivatives  may  be  used,  but,  when 
antipyrin  or  phenacetin  are  used  and  appear  to  in- 
crease diaphoresis,  it  is  best  to  change  to  other 
methods,  or  give  them  in  much  smaller  doses. 

Hydropathic  measures  for  reducing  fever  are  not 
used  to  any  great  extent  in  phthisis.  Sponging  the 
body  under  cover  may  be  used. 

Night  Sweats.  Sponging  with  equal  parts  of 
water  and  alcohol  on  going  to  bed,  and,  if  necessary, 
during  the  night,  may  prevent  them.  Brandy,  a  tea- 
spoonful  in  a  cup  of  hot  or  cold  milk,  may  be  given 
at  bedtime.  An  ounce  of  whisky  may  be  adminis- 
tered a  short  time  before  the  expected  sweat. 

Atropin  sulphate  gr.  Kso  in  tablets  may  be  given 
hourly  in  the  evening  for  4  or  5  doses. 

Agaricin  may  be  used,  but,  owing  to  its  tendency 
to  produce  diarrhea,  it  is  better  to  combine  it  with 
Dover's  powder. 

IJi     Agaricini    gr.  iij 

Pulveris   Doveri    gr.  xxx 

Althsese, 

Mueilaginis  acacise    aa  q.  s. 

Misce  et  fiat  massa.     Divide  pilulse  No.  XX. 

Sig. :   1  or  2  pills  five  hours  before  the  expected  sTveat. 

Camphoric  acid  has  the  advantage  of  producing 
quick  effect,  which  lasts  for  six  hours.  It  is  given 
in  capsule  of  1  or  2  grains  in  the  evening. 

A  dusting  powder  of  either  tannoform  or  zinc 
peroxid,  to  be  dusted  over  the  skin,  is  often  very 
beneficial  in  checking  the  sweat. 


PULMONARY   TUBERCULOSIS.  209 

IJ.     Zinci  peroxidi   Ej 

Talci  purificati    S  iss 

Misce  et  fiat  pulveris. 

Sig. :  To  be  dusted  on  the  skin. 

Cough.  Is  often  torturous  and  prevents  rest. 
Patient  should  be  taught  how  to  cough  to  raise 
sputum  by  a  deep,  slow  inspiration,  followed  by  a 
short,  quick  expiration. 

"When  the  nose,  pharynx,  or  larynx  is  not  the 
cause,  then  codein  should  be  used  to  check  it.  Some- 
times local  treatment  to  the  upper  portion  of  the 
respiratory  tract  is  all  that  is  necessary.  ■ 

I^     Codeinse  phosphatis    gr.  viij 

Acidi   hydrocyanici   diluti    3  j 

Spiritus   chloroformi    3  iss 

Syrupi  lemonis   3  j 

AquEe    q.  s.  ad  §  iv 

Misce. 

Sig.:  Teaspoonful  when  cough  is  troublesome. 

Or: 

I^     Dionini    gr.  iv 

Acidi  hydrocyanici  diluti   TTl,  xxx 

Syrupi  tolutani  3  vi 

Aquse    q.  s.  ad  §  ij 

Misce. 

Sig. :   Teaspoonful  every  three  hours  for  cough. 

Hemorrhage  is  best  treated  by  recumbent  posture 
of  the  patient,  with  head  propped  up,  and  positive 
assurance  of  the  physician  that  all  will  be  right. 
Place  an  ice  bag  over  the  pericardium  to  quiet  the 
heart  and  give  hypodermic  of  morphin  gr.  ^-gr.  Yz. 
Nitroglycerin  to  lower  blood  pressure  is  recom- 
mended by  some. 


210       DISEASES    OF   THE    LUNGS   AND    PLEURA. 

Calcium  lactate  in  half-dram  doses  three  times  a 
day  for  two  days  may  stop  repeated  small  hemor- 
rhages. 

Adrenalin  hypodermatically  and  salt  solution 
should  be  used  when  large  hemorrhage  endangers 
life. 

Mercurial  Treatment  of  Tuberculosis. 

Excellent  results  are  reported  from  the  new  Fort 
Lyon  Naval  Hospital  by  hypodermatic  use  of  mer- 
cury succinimide.  Two  strengths  are  used — gr.  M.o 
and  gr.  %  to  the  tablet.  One  injection  of  gr.  K  is 
given  every  other  day  until  thirty  injections  have 
been  given;  then  one  week's  rest,  when  injections 
are  resumed,  using  gr.  %  and  gr.  %o  alternately, 
and  later  gr.  %o  was  used.  A  later  method  has  been 
advised  of  administering  the  drug  in  gradually  in- 
creasing doses  until  the  therapeutic  limit  is  reached. 
When  the  maximum  dose  for  the  patient  is  estab- 
lished, it  is  divided  by  two  and  the  injections  con- 
tinued on  this  basis.  The  open  air  and  food  treat- 
ment is  also  carried  out  in  conjunction  with  the 
mercury  treatment. 

At  present  it  is  better  not  to  attempt  the  use  of 
tuberculin  as  a  curative  measure. 

As  to  the  advisability  of  sending  tubercular  pa- 
tients away  from  home,  we  are  strongly  opposed. 
Nothing  can  be  worse  than  to  be  seriously  sick  in  a 
strange  land  among  strangers.  There  is  nothing  to 
be  gained  away  from  home  that  can  not  be  had  at 


PULMONARY  TUBERCULOSIS ACUTE  PLEURISY.  211 

home.  There  are  many  devices  to  apply  to  a  win- 
dow and  to  the  patient's  bed  in  such  a  manner  that 
the  head  and  shoulders  are  in  the  open  air,  while 
the  body  is  protected. 

Finally,  let  us  urge  a  careful  supervision  by  the 
attending  physician  of  the  patient's  sputum.  Let 
the  short,  concise  statement  ring  in  our  ears,  "No 
sputum,  no  tuberculosis."  A  piece  of  paper,  rectan- 
gular in  shape,  rolled  cornerwise  so  as  to  form  a 
funnel,  and  the  pointed  end  doubled  back,  makes  an 
excellent  spit  cup,  that  should  be  used  and  thrown 
into  the  fire. 

Acute  Pleurisy. 

Remember  that  in  children  or  the  aged  the  only 
symptoms  that  may  be  present  are  dyspnea  on  exer- 
tion and  increasing  pallor. 

Remember  that  chill,  fever,  and  pain,  or  "stitch 
in  the  side, ' '  usually  announce  the  onset  of  pleurisy. 

Remember  that  the  pain  is  sharp  and  lancinating, 
and  the  cough  makes  it  worse. 

Remember  that  on  auscultation  a  dry,  friction  rub 
is  heard  prior  to  the  exudate,  and  this  friction  sound 
is  pathognomonic. 

Remember  that  fever  does  not  rise  so  rapidly  nor 
'  so  high  as  in  pneumonia. 

Remember  that  the  pain  may  be  felt  in  the  abdo- 
men or  low  down  in  the  back. 

"    Don't  mistake  the  dry,   crepitant  rales  for  the 
friction  sound.    The  friction  sound  is  not  continu- 


212        DISEASES    OF   THE   LUNGS   AND    PLEUE^. 

ous,  and  not  restricted  to  inspiration  as  are  crepitant 
rales,  but  is  divided  between  inspiration  and  expira- 
tion, and  is  distinguished  as  being  very  superficial, 
or  close  to  the  ear.  Coughing  up  the  secretions  has 
no  effect  upon  the  pleuritic  sound. 

Remember  that  effusion  into  the  pleural  sac  causes 
marked  changes.  The  friction  rub  heard  on  auscul- 
tation, and  so  characteristic  of  pleurisy  in  the  early 
stage,  disappears. 

Remember  that  bulging  of  the  intercostal  spaces 
signifies  effusion. 

Remember  that  the  patient  changes  posture,  and 
now  lies  on  the  affected  side  to  give  more  freedom 
in  breathing. 

Remember  that  on  auscultation  the  breath  sounds 
are  distant  and  tubular,  and  vocal  resonance  on  pal- 
pation is  diminished  or  absent. 

Remember  that  the  dullness  on  percussion  over 
an  effusion  is  flat,  and  there  is  a  sense  of  resistance 
to  the  fingers. 

Remember  Grocco's  triangle  of  dullness  in  effu- 
sion. It  is  found  along  the  spine  on  the  side  oppo- 
site the  effusion,  and  from  one-quarter  to  one  inch 
wide,  with  apex  upward.  It  is  due  to  the  displace- 
ment of  the  mediastinum  by  the  fluid.  The  patient 
should  be  in  the  sitting  posture. 

Remember  that  Skoda 's  resonance  is  found  just 
above  the  line  of  effusion,  posteriorly  as  well  as  in 
the  subclavicular  space.  It  is  a  tympanitic  note, 
due  to  the  compression  of  the  lung. 


ACUTE    PLEURISY.  213 

Remember  that  the  insertion  of  the  hypodermic 
needle  under  aseptic  precautions  and  the  withdrawal 
of  fluid  determines  two  points — viz.,  an  effusion  and 
whether  serous  or  purulent. 

Remember  that  liquid  in  pleural  sac  will  cause 
displacement  of  organs,  and  the  cardiac  displace- 
ment is  the  one  most  easily  determined. 

Remember  that  in  a  tumor  of  the  mediastinum  the 
dullness  usually  extends  from  below  upward,  is 
irregular  in  outline,  and  not  restricted  to  one  side. 

Remember  that  as  the  tumor  grows  there  will  be 
compression  of  nerves,  vessels,  and  esophagus. 

Remember  the  following  points  in  differentiating 
pleurisy  and  pneumonia: 

1.  Dullness  of  pleurisy  is  absolute  (woody),  offer- 
ing great  resistance  on  percussion. 

2.  Pectoral  fremitus  absent  or  diminished  over  an 
effusion. 

3.  Crepitant  rale  is  absent  in  pleurisy. 

4.  Displacement  of  organs  is  marked  in  effusion. 

5.  Sputum  of  pneumonia  always  present  and 
rusty-colored. 

6.  Fever  of  pneumonia  is  high. 

Treatment. 

Patient  should  be  put  to  bed. 

Pain  in  the  early  stages  is  the  most  urgent  symp- 
tom for  treatment. 

A  hypodermic  of  morphin  is  the  best  way  to  re- 
lieve it. 


214        DISEASES    OF    THE    LUNGS    AND    PLEUE^. 

The  ice  bag  to  the  affected  side,  leeches,  hot 
fomentations,  or  mustard  plaster  will  give  relief 
where  pain  is  not  severe. 

Immobilizing  the  side  gives  prompt  relief.  Ad- 
hesive strips  are  nsed.  They  are  cut  long — ^long 
enough  to  extend  about  two  inches  beyond  the  me- 
dian line  posteriorly  and  anteriorly.  The  three-inch 
is  best,  and  the  strips  should  overlap  one-third. 
They  should  be  applied  with  the  lungs  as  near  col- 
lapsed as  possible — at  complete  expiration — begin- 
ning at  the  lower  margin  and  strapping  upward 
until  the  axilla  is  reached. 

Calomel,  followed  by  saline,  should  be  given. 

Diet  should  be  light.  When  effusion  occurs,  it 
should  be  dry.  No  liquids  be  given.  'Concentrated 
saline  purges  should  be  given  in  the  morning  before 
breakfast.    Salt  should  be  withheld. 

Effusion  is  best  relieved  by  aspiration.  An  ordi- 
nary trocar  may  be  used  or  Potain's  aspirating  set 
may  be  obtained.  The  site  depends  upon  the  loca- 
tion of  the  liquid — usually  in  the  midaxillary  line, 
in  the  seventh  intercostal  space.  The  skin  is  thor- 
oughly cleansed.  The  patient  places  the  hand  of 
the  affected  side  on  the  shoulder  of  the  opposite 
side,  thus  widening  the  intercostal  spaces.  The 
needle  is  thrust  in  close  to  the  upper  margin  of  the 
rib,  so  as  to  avoid  wounding  the  artery.  The  amount 
of  fluid  to  be  drawn  off  depends  upon  the  reaction 
of  the  patient.  All  of  a  large  exudate  should  not 
be  withdrawn  at  one  time,  as  a  severe  paroxysm  of 


ACUTE    PLEURISY.  215 

coughing  is  caused  by  sudden  relief  of  the  pressure 
upon  the  lung. 

In  early  stage,  when  fever  and  circulatory  excite- 
ment exist  before  effusion  occurs,  the  following 
may  be  administered: 

IJ     Tincturse    aconiti    TTI,  x 

Spiritus  aetheris  nitrosi    3  j 

Syrupi  pruni  virginianse    3  iv 

Liquoris  potassii  citratis    . .  q.  s.  ad  §  iij 
Misce. 

Sig. :  Tablespoonful  hourly  until  pulse  becomes  soft,  then 
every  two  hours. 

Or: 

J^     Potassii    citratis     3  v 

Antipyrini    3  j 

Liquoris  ammonii  acetatis   §  iij 

Syrupi  limonis    5  i j 

Aquae    q.  s.  ad  §  viij 

Misce. 

Sig.:    Tablespoonful   hourly   for   four    doses,    then    every 
two  or  three  hours. 

lodid  of  potash  and  sodium  salicylate  are  of  little 
benefit,  although  frequently  used.  They  are  very 
liable  to  upset  the  stomach. 


CHAPTEE  XI. 

INFECTIOUS  DISEASES. 

Typhoid  (Enteric  Fever). 

Remember  that,  while  the  disease  is  more  common 
in  early  adults,  the  disease  is  often  seen  in  children. 

Remember  that  in  children  there  is  frequently  ab- 
sent some  of  the  usually  constant  symptoms. 

Remember  that  the  onset  in  children  may  be  so 
sudden  and  the  diarrhea  so  severe  that  acute  en- 
teritis is  diagnosed. 

Remember  that,  as  a  rule,  the  onset  is  gradual, 
and  that  for  ten  days  or  two  weeks  there  are  lassi- 
tude and  inaptitude  for  work. 

Remember  that  nose  bleed  is  an  early  and  fairly 
constant  sign  in  typhoid,  especially  when  the  pa- 
tient is  not  subject  to  epistaxis  in  health. 

Remember  that  headache  is  an  early  and  fairly 
constant  symptom,  and  occasionally  it  may  be  very 
severe,  accompanied  by  photophobia,  retraction  of 
the  head,  and  muscular  twitching,  suggesting  menin- 
gitis. 

Remember  that  severe  facial  neuralgia  may  mark 
the  onset  of  typhoid. 

Remember  that  the  first  intimation  may  be  acute 
mania,  pronounced  delirium,  or  drowsiness  and 
stupor,  simulating  basilar  meningitis. 

Remember  that  an  initial  bronchitis  is  very  com- 

216 


TYPHOID.  217 

mon  in  typhoid,  but  occasionally  it  is  of  so  great  a 
severity  as  to  obscure  other  features  of  the  disease. 

Remember  that  the  onset  may  be  by  a  chill,  pain 
in  the  side,  hurried  breathing,  and  pleurisy,  or  pneu- 
monia may  be  suspected. 

Remember  that  severe  abdominal  pain  and  tender- 
ness in  the  appendiceal  region  has  led  to  a  diag- 
nosis of  appendicitis. 

Remember  that  at  the  beginning  of  typhoid  the 
cheeks  are  flushed  and  the  eyes  are  bright,  but  at 
the  close  of  the  first  week  we  find  the  dull,  heavy 
look  so  familiar. 

Remember  that  the  fever  may  not  be  of  the  ordi- 
nary type.  There  may  be  a  rapid  rise  to  103°  or 
104°  F.  following  a  chill  or  convulsion.  Usually  the 
"step-ladder"  rise  of  the  temperature  from  day  to 
day  during  the  first  week  is  observed. 

Remember  that  after  the  fastigium  is  reached  the 
fever  continues  with  but  slight  daily  remissions.  As 
a  rule,  the  fever  terminates  by  lysis,  but  it  may  dis- 
appear rapidly  and  in  twenty-four  hours  the  tem- 
perature be  normal.  This  may  be  associated  with 
severe  sweating. 

Remember  that  a  sudden  drop  in  the  temperature 
strongly  indicates  intestinal  hemorrhage. 

Remember  that  "rose  spots"  are  not  present  in 
all  cases  of  typhoid,  but  that  when  present  they  are 
pathognomonic  of  the  infection.  They  are  small  red 
spots  found  on  the  abdomen,  that  disappear  on  pres- 
sure and  come  in  crops.    They  make  their  appear- 


218  IKFECTIOUS   DISEASES. 

ance  from  the  seventh  to  the  tenth  day.  There  may 
be  few  on  the  abdomen  and  the  eruption  may  be 
general. 

Remember  that  while  a  dry,  hot  skin  is  usually 
found  at  the  height  of  the  fever,  there  are  cases 
where  sweating  is  characteristic;  usually  associated 
with  chilly  sensations. 

Remember  that  paroxysms  of  chills,  fever,  and 
sweats  may  occur,  and  thus  simulate  malaria,  but 
they  are  lacking  in  periodicity  and  may  occur  sev- 
eral times  in  the  twenty-four  hours. 

Remember  that  the  dicrotic  pulse  is  more  often 
found  in  typhoid  than  in  any  other  condition,  and 
that  the  increase  of  the  pulse  rate  is  not  propor- 
tionate to  the  increased  temperature. 

Remember  that  an  enlarged,  soft  spleen  is  an  al- 
most constant  clinical  symptom  of  typhoid.  If  the 
vertical  dullness  over  the  splenic  area  exceeds  the 
depth  of  two  ribs  and  an  interspace,  enlargement  is 
present.  The  best  way  to  determine  enlargement  is 
by  palpation. 

Remember  that  the  "pea-soup"  stools  occur  in 
the  second  week,  as  does  also  status  typhosus — 
stupor,  somnolence,  difficulty  of  hearing,  indistinct- 
ness of  speech,  muttering  delirium,  and  picking  at 
the  bed  clothes. 

Remember  that  the  agglutination  test  of  Widal  is 
the  most  conclusive  sign  we  have  of  typhoid  infec- 
tion. 

Remember  that  the  results  of  the  test  are  just  as 


TYPHOID.  219 

good  if  you  use  cultures  of  dead  bacilli,  and  the 
microscope  is  not  needed  to  determine  a  positive  or 
negative  reaction. 

Remember  that  many  tests  should  be  made  in 
case  the  first  proves  negative,  because  the  formation 
of  antibodies  is  often  delayed  and  the  reaction  not 
obtained  until  late  in  the  disease. 

Remember  that  a  sudden  drop  in  the  temperature, 
feeble  and  rapid  pulse,  and  pallor  are  unequivocal 
signs  of  hemorrhage,  even  though  it  has  not  yet 
appeared  in  the  stools.  This  accident  most  often 
occurs  in  the  second  or  third  week  of  the  course  of 
the  disease. 

Remember  that  the  signs  of  perforation  are  never 
the  same  as  those  of  peritonitis,  and  it  is  reprehen- 
sible for  a  physician  to  await  the  onset  of  the  latter, 
as  the  few  hours  intervening  between  the  occurrence 
of  the  one  and  the  onset  of  the  other  are  the  life- 
saving  hours. 

Remember  that  the  signs  of  perforation  are: 

1.  A  sharp,  severe  pain,  often  paroxysmal  in 
character,  in  the  hypogastric  region  and  to  the  right 
of  the  median  line. 

2.  Tenderness  on  pressure,  most  marked  in  the 
hypogastrium. 

3.  Muscular  rigidity  on  light  palpation. 

4.  Drop  in  the  temperature,  sweating,  and  increase 
rate  of  pulse  and  respiration. 

Remember  that  at  this  period  the  patient  becomes 
an  urgent  case  for  the  surgeon  and  ceases  to  be  a 
proper  case  for  the  internist. 


220  INFECTIOUS   DISEASES. 

Remember  that  after  four  to  six  hours  peritonitis 
follows  perforation;  the  temperature  rises;  balloon- 
ing of  abdomen;  disappearance  of  liver  dullness; 
muscular  rigidity;  rapid,  feeble  pulse;  cold  sweat — 
death. 

Treatment. 

Diet.  There  are  two  views  relative  to  the  diet. 
On  the  one  hand,  we  have  those  who  restrict  the 
diet  to  liquid.  A  representative  of  this  type  is  the 
one  used  by  Osier  and  McCrea,  consisting  of  4 
to  6  ounces  of  milk,  diluted  with  2  ounces  of 
lime  water,  every  four  hours,  and  4  ounces  of 
albumen  water,  made  from  the  white  of  one  or  two 
eggs,  every  four  hours.  They  claim  that  even  that 
amount  is  probably  too  much.  On  the  other  hand, 
a  number  of  excellent  physicians  are  using  a  more 
liberal  diet — treating  the  patient  rather  than  the 
disease.  Dr.  F.  C.  Shattuck's  menu  may  be  quoted 
as  representing  this  view: 

1.  Milk — hot,  cold,  diluted  with  lime  water,  soda 
water;  peptonized  milk;  cream  and  water;  milk  with 
white  of  egg;  buttermilk;  matzoon;  milk  whey;  milk 
with  tea,  coffee,  or  cocoa. 

2.  Soups — beef,  veal,  chicken,  tomato,  potato,  oys- 
ter, mutton,  pea,  bean,  squash;  carefully  strained 
and  thickened  with  arrow-root,  flour,  milk  or  cream, 
egg,  barley. 

3.  Malted  milk— Horlick 's,  Mellin's. 

4.  Beef  juice. 


TYPHOID.  221 

5.  Gruels — strained  cornmeal,  crackers,  flour,  bar- 
ley water,  toast  water,  albumen  water  with  lemon 
juice. 

6.  Ice  cream. 

7.  Egg — soft  boiled  or  raw;  egg-nog. 

8.  Finally,  minced  lean  meat,  scraped  beef,  the 
soft  part  of  raw  oysters,  soft  toast,  jelly,  apple  sauce, 
and  macaroni. 

It  is  probably  true  that  we  have  been  feeding  too 
little  and  the  patient  enters  upon  his  period  of  con- 
valescence handicapped. 

Liquids.  Typhoid  patients  must  be  given  water 
freely,  unless  contraindicated  by  extreme  arterio- 
sclerosis, myocarditis,  or  serious  valvular  lesion. 
In  addition  to  the  liquid  in  the  food,  they  should  be 
given  from  a  half  to  two  quarts  daily.  The  severer 
the  toxemia,  the  more  water  should  be  given. 

Lemonade  is  excellent,  because  it  excites  the  flow 
of  saliva  and  prevents  the  mouth  becoming  dry. 

Alcohol  should  be  given  in  cases  of  profound 
toxemia  and  the  heart  feeble;  8  to  12  ounces  of 
whisky  may  be  given  in  the  twenty-four  hours.  One 
strong  indorsement  for  a  liberal  diet  is  the  fact  that 
the  patient  seldom  needs  whisky. 

Where  the  tub  bath  is  used  and  the  patient  re- 
quires whisky,  it  should  be  given  just  before  or  after 
the  bath,  depending  upon  his  reaction  to  the  bath. 

Hydrotherapy.  This  is  next  in  importance  to  the 
diet.  The  bath,  cold  packs,  or  sponging  may  be  used. 
Of  the  various  methods  of  applying  water,  the  bath 
is  best  when  not  contraindicated. 


222  INFECTIOUS   DISEASES. 

Baths.  Are  not  only  given  to  reduce  the  tempera- 
ture, but  they  mitigate  the  nervous  symptoms,  and 
thus  lessen  the  delirium,  stimulate  the  kidneys,  and 
thus  increase  the  excretions  of  toxins,  and  cleanse 
the  skin — in  short,  affect  favorably  the  whole  course 
of  the  disease.  It  is  best  to  begin  with  water  at  80° 
or  85°  F.,  and  gradually  reduce  the  temperature 
after  placing  the  patient  in  the  tub.  Always  apply 
cold  to  the  head.  Gently,  but  briskly,  rub  the  pa- 
tient while  in  the  bath.  The  bath  should  last  from 
ten  to  fifteen  minutes,  and  the  patient  is  placed  be- 
tween sheets  and  covered  with  a  blanket  after 
removal  and  drying.  The  temperature  should  be 
taken  immediately  after  the  bath  and  again  in  an 
hour.  These  baths  may  be  repeated  as  often  as  the 
temperature  reaches  103°  F.  A  cup  of  hot  milk  may 
be  given  and  hot-water  bottle  placed  to  the  feet. 

Cold  Packs.  A  sheet  is  wrung  out  of  cold  water 
and  the  patient  wrapped  in  it.  The  head  and  feet 
are  left  free.  Cold  water  may  be  sprinkled  over 
him  occasionally,  or  he  may  be  rubbed  with  a  piece 
of  ice,  especially  along  the  vertebrae.  The  pack  is 
removed  in  from  twenty  to  thirty  minutes,  the  body 
dried  and  covered  with  sheet  and  blanket. 

This  may  be  repeated  as  often  as  the  temperature 
indicates  it.  Cool  sponging  may  be  resorted  to  in 
mild  cases.  Alcohol  or  vinegar  should  be  added  to 
the  water.  The  skin  should  be  only  partially  dried, 
so  that  by  evaporation  of  the  moisture  on  the  skin 
a  continuation  of  the  antipyretic  effect  may  be  ob- 
tained. 


TYPHOID.  223 

Contraindications  for  cold  baths  or  packs  are  in- 
testinal hemorrhage,  perforation,  the  old  and  very 
young;  patients  suffering  -with  acute  or  serious 
chronic  cardiac  or  cardiovascular  changes,  phlebitis, 
nephritis,  pneumonia,  pregnancy;  very  obese,  ane- 
mic,  and  alcoholics. 

Medicinal  Antipyretics.  These  should  not  be 
given  unless  baths  can  not  be  used,  either  because 
of  contraindications  or  prejudices  of  the  family. 
There  are  a  number  of  drugs  that  are  antip^Tetic — 
quinin,  phenacetin,  antipyrin,  pyramidon. 

Quinin  should  not  be  given  to  typhoid  patients  in 
doses  large  enough  to  reduce  temperature.  From 
recent  laboratory  reports  quinin  in  2-gTain  doses 
every  three  hours  vrill  stimulate  phagocytosis,  and 
perhaps  will  thus  assist  the  body  in  fighting  the 
invaders,  but  the  dose  is  too  small  to  affect  the 
fever;  and  the  laboratory  has  also  shown  that  quinin 
in  large  doses  destroys  the  ameboid  movement  of 
leucocytes,  and  thus  interferes  with  the  resisting 
forces. 

Antipyrin  and  phenacetin  are  better  not  used  in 
typhoid,  because  of  the  cardiac  depressing  effect. 

Pyramidon  is  given  gr.  iij-gr.  iv  every  two  or 
three  hours,  and  it  is  claimed  by  good  observers  to 
have  no  ill  effect,  except  that  in  some  patients  it 
produces  excessive  diaphoresis.  As  a  precaution,  it 
may  be  combined  with  3  to  4  grains  of  sodium  ben- 
zoate  of  caffein. 

Calomel  should  be  given  at  the  onset,  and  repeated 


224  IKFECTIOUS    DISEASES. 

throughout  the  disease  when  tympany  indicates  ex- 
tensive gas  formation  in  the  bowel.  Gr.  v-gr.  x  may 
be  given  in  one  dose,  or  it  may  be  administered  in 
broken  doses.  Nobody  claims  it  cuts  short  the 
course  of  typhoid,  but  the  experience  of  clinicians 
is  favorable  to  its  use  because  of  its  combined 
powers  as  an  antiseptic,  glandular  stimulant,  and 
eliminant  both  through  the  bowels  and  kidneys. 

Intestinal  antiseptics  are  indicated,  but  not,  as 
some  think,  to  cut  short  the  disease  nor  to  abort  it. 
They  reduce  the  bacterial  activity  in  the  intestines 
and  thus  favorably  influence  the  disease.  Turpen- 
tine in  emulsion  is  best  and  the  sulphocarbolates 
follow. 

The  following  are  excellent  combinations: 

IJ     Naphtolis    3  j 

Salolis     gr.  xxx 

Pulveris   aromatieee    gr.  xx 

Misee  et  fiant  pulveres  No.  XII. 

Sig. :  Powder  every  four  hours. 


Or: 


IJ     Bismuthi   salicylatis    3  iij 

Iclithalbini     3  iij 

Sacchari   lactis    3  j 

Misce  et  fiant  pulveres  No.  XXIV. 

Sig.:  Powder  every  four  hours. 


Or: 


3     Sodii   sulphocarbolatis    3  iij 

Resorcinolis    (Merck)     gr.  xxx 

Syrupi  simplicis   §  ij 

Aquae  menthse  piperitse  ^iv 

Misce. 

Sig.:    Tablespoonful  every  fovir  hours. 


TYPHOID.  225 

Or: 

IJ.     Zinci    sulphocarbolatis    gr.  ss 

Calcii    sulphocarbolatis    gr.  j 

Sodii    sulphocarbolatis    gr.  iiiss 

Bismuthi   salicylatis    gr.  % 

Mentholis     gr.  j 

Misce  et  fiat  pulvere  Xo.  I. 

Sig. :  Powder  every  three  to  six  hours,  according    to    odor 
of  stools. 

This  combination  is  put  up  in  tablet  form  by 
Abbott,  and  is  very  convenient  and  effective.    Or : 

IJ     Olei    terebinthinse     3  iss 

Olei  caryophylli    gtt.  vj 

Glycerini, 

Mucilaginis   acaciae    aa  §  ss 

Aquae    destillatse    q.  s.  ad  g  iij 

Misce  et  fiat  mistura^. 

Sig.:    Dessertspoonful   every  two   hours  during  the  day. 

Thymol  is  preferred  by  some,  because  it  possesses 
antiseptic  power  four  times  as  great  as  carbolic 
acid  and  is  innoxious;  it  is  also  insoluble,  so  that  it 
reaches  the  intestines.  It  is  given  in  gr.  ij-gr.  iij 
every  three  hours,  made  into  a  pill,  and  should  al- 
ways be  given  with  food. 

Mouth,  teeth,  and  tongue  should  be  thoroughly 
cleansed  after  each  feeding.  The  mouth  and  teeth 
should  be  washed  with  weak  alkaline  solution.  Bak- 
ing soda  in  warm  water  is  excellent,  and,  if  the  pa- 
tient is  able,  he  should  rinse  the  mouth  with  some 
mild  antiseptic  solution. 

Bed  sores  are  rare  where  bathing  is  used  in  the 
treatment.  It  is  well  to  rub  the  skin  over  the  but- 
tocks, thighs,  and  lower  back  with  a  weak  bichlorid 


226  INFECTIOUS    DISEASES. 

solution,  followed  with  alcohol;  rub  dry  and  dust 
with  some  simple  powder  or  talcum. 

Diarrhea  demands  treatment  when  the  daily 
evacuations  exceed  six.  Silver  nitrate  gr.  %-gr.  ^/4 
is  called  a  specific  by  some.  Bismuth  subnitrate  or 
salicylate  gr.  v-gr.  x,  with  paregoric  3  ss,  every  two 
or  three  hours,  is  useful,  or  the  following: 

R.     Pulveris    opii     gr.  % 

Pulveris  camphorse  gr.  j 

Plumbi  acetatis    gr.  iij 

Bismuthi  subnitratis   gr.  xxx 

Misce  et  fiat  pulvere  No.  I.     Dentur  tales  pulveres  No.  XII. 

Sig. :  Powder  every  four  hours. 

Or: 

IJ     Bismuthi  subnitratis   3  i  j 

Tannalbini     3  iij 

Dionini    gr.  ij 

Misce  et  fiant  pulveres  No.  XII. 
Sig.:   Powder  every  three  hours. 

Meteorism.  First  insert  a  large  rubber  catheter. 
Turpentine  stupe  to  the  abdomen.  A  careful  re- 
vision of  the  diet — as  the  omission  of  gruels  and 
peptonizing  of  the  milk.  Eserin  gr.  %o  may  be 
given. 

Hemorrhage.  Apply  cold  to  abdomen — as  light 
ice  bag.  Stop  everything  by  mouth,  except  cold  albu- 
men water.  If  patient  is  restless,  give  morphin  hy- 
podermatically.  Administer  calcium  salts  in  large 
doses.  In  large  hemorrhage,  manifested  by  weak, 
rapid  pulse  and  signs  of  collapse,  give  saline  solu- 
tion into  the  subcutaneous  tissues  or  into  the  vein, 
according  to  the  urgency  of  the  case.    It  is  best  to 


TYPHOID BACILLARY   DYSENTERY.  227 

omit  the  morphin  if  possible,  and  in  no  case  should 
the  sensorium  be  completely  obtunded,  because  per- 
foration may  occur  and  pain  is  our  principal  guide. 

IJ     Stypticini    gr.  xi j 

Ergotini    gr.  xxx 

Elixiris  simplicis    §  iij 

Misce. 

Sig. :    Tablespoonful  every  two  to  three  hours. 

Perforation  requires  an  immediate  operation,  un- 
der general  anesthesia  if  possible  or  under  cocain. 
There  can  be  no  delay,  as  peritonitis  will  inevitably 
follow  in  five  or  six  hours. 

Urotropin  gr.  v-gr.  x  should  be  administered  three 
times  daily  for  its  antiseptic  powers  in  the  bile, 
urine,  and  cerebrospinal  fluid.  Many  cases  of  gall- 
stones will  thus  be  prevented  and  the  urine  will  not 
become  a  distributor  of  the  germs.  This  drug  should 
be  administered  during  the  period  of  convalescence 
as  well. 

Tonics,  and  good  food  and  fresh  air  in  abundance 
should  be  given  the  convalescent. 

Children  should  not  be  returned  to  school  before 
six  months  following  typhoid. 

Bacillary  Dysentery. 

Remember  that  this  affection  often  appears  in 
epidemics,  in  which  children  are  attacked  as  well  as 
adults. 

Remember  that  hot  weather  and  improper  feed- 
ing of  children  is  a  very  frequent  cause. 

Remember  that  the  onset  is  usually  sudden,  and 


228  INFECTIOUS   DISEASES. 

is  characterized  by  slight  fever,  pain  in  the  ab- 
domen, and  frequent  stools. 

Remember  that  the  stools  at  first  contain  a  large 
amount  of  mucus,  but  in  twenty-four  hours  blood  is 
passed  with  it. 

Remember  that  frequently  pure  blood  is  passed; 
hence  ''bloody  flux." 

Remember  that  there  is  a  constant  desire  to  go  to 
stool.    The  motion  of  the  bowels  affords  no  relief. 

Remember  that  straining  and  tenesmus  while  at 
stool  is  very  characteristic. 

Remember  that  the  temperature  gradually  rises, 
and  the  pulse  becomes  rapid  and  small. 

Remember  that  the  frequent  stools  cause  great 
thirst  and  rapid  emaciation. 

Remember  that  the  blood  of  the  patient  in  dilu- 
tion will  agglutinate  the  Flexner-Harris  or  Shiga 
bacilli,  depending  upon  the  bacilli  causing  the  in- 
fection. 

Remember  that  the  bacilli  dysenterise  should  be 
sought  for  with  the  microscope  in  the  shreds  of 
mucus  found  in  the  stools. 

Remember  that  liver  abscess  is  not  a  complication 
of  bacillary  dysentery. 

Remember  that  severe  and  painful  joint  symp- 
toms may  be  associated  and  lead  to  an  erroneous 
idea  of  acute  rheumatism. 

Remember  that  paralysis  frequently  follows  bacil- 
lary dysentery.  It  is  usually  in  the  form  of  para- 
plegia. 


bacillary  dysentery.  229 

Treatment. 

The  patient  should  be  confined  to  bed,  as  absolute 
rest  is  necessary  in  acute  stage.  When  the  pain  is 
severe,  a  hypodermic  of  morphin  should  be  given. 

Diet  must  be  restricted  to  milk,  whey,  and  broths. 
During  an  acute  attack  neither  ice  nor  cold  liquids 
should  be  swallowed,  although  the  mouth  may  be 
rinsed  with  cold  water  to  relieve  thirst.  In  the 
severe  cases  peptonized  milk  should  be  given.  Dur- 
ing convalescence  great  care  must  be  exercised 
in  the  diet.  Nutritious  and  easily  digested  food 
should  be  selected,  and  solid  food  should  be  with- 
held until  all  signs  of  enteritis  have  disappeared  and 
the  stools  are  normal. 

Medicinal.  When  seen  early,  a  dram  of  mag- 
nesium or  sodium  sulphate  every  two  hours  until 
the  stools  are  watery.  The  continuous  administra- 
tion of  the  salines  is  the  best  form  of  treatment. 
The  following  give  excellent  satisfaction: 

R     Solutionis  magnesii  sulphatis  satu- 

rationis     §  j 

Tincturse  opii, 

Acidi  sulphuric!  aromatici   aa  3  iv 

Essentise  pepsini  ( Fairchild )  q.  s.  ad  S  iij 
Misce. 
Sig. :  Teaspoonful  every  three  hours. 


Or: 


IJ     Cupri  sulphatis  gr.  ss 

Magnesii    sulphatis    5  j 

Acidi  sulphurici  diluti   3  j 

Aquae  menthse  piperitse    .  .  .  .  q.  s.  ad  5  iv 

Misce. 

Sig. :    Teaspoonful  every  four  hours. 


230  INFECTIOUS   DISEASES. 

Or: 

IJ     Cupri  arsenitis    gr.  % 

Tincturae  opii  camphorse   3  iv 

Essentiae  pepsini  (Fairchild)    q.  s.  ad  5  iij 
Misce. 
Sig. :  Teaspoonf ul  every  three  hours. 

Bichlorid  of  mercury  in  gr.  %oo-gr.  Vso  every  two 
hours  often  gives  excellent  results. 

Bismuth  is  given  frequently,  but  it  is  more  effica- 
cious in  the  chronic  form.  When  used,  it  should  be 
given  in  massive  doses,  3  ss-o  j,  best  given  alone 
mixed  with  water. 

Ipecac  in  large  doses  is  used  extensively.  No 
food  is  given  for  three  hours,  then  15  or  20  drops  of 
the  tincture  of  opium  is  given,  and  in  half  an  hour 
5  ss-5  j  of  ipecac  is  given  and  the  patient  kept  quiet 
on  his  back.  Should  it  be  vomited,  it  is  repeated  in 
one  or  two  hours.  After  the  acute  symptoms  sub- 
side, rectal  irrigation  should  be  begun.  There  are  a 
number  of  astringents — such  as  alum,  acetate  of 
lead,  sulphate  of  copper  and  zinc,  and  silver  nitrate. 
Silver  nitrate  is  best,  and  large  quantities  of  the 
solution  should  be  used,  so  that  all  parts  of  the 
colon  will  be  thoroughly  irrigated;  20  to  30  grains 
to  the  pint  and  5  to  6  pints  should  be  used  at  a 
time.  The  more  chronic  the  condition,  the  better 
will  be  the  result. 

Local  Applications.  Hot  turpentine  stupe  or 
poultice  will  relieve  pain  and  reduce  the  number  of 
stools. 

Serum  therapy  is  not  at  all  satisfactory,  and  we 
must  await  further  developments  along  this  line. 


AMEBIC    DYSENTEKY.  231 

Amebic  Dysentery. 

Remember  that  there  are  two  forms — the  acute 
and  chronic — both  caused  by  the  ameba  dysenterise. 

Remember  that  the  acute  form  is  characterized 
by  a  sudden  onset,  with  pain,  tenesmus,  and  diar- 
rhea, the  stools  containing  blood  and  mucus. 

Remember  that,  though  the  fever  is  not  intense, 
there  is  rapid  emaciation,  and  the  patient  may  die 
in  a  week. 

Remember  that  hemorrhage  of  the  bowel  or  per- 
foration, with  peritonitis,  may  occur. 

Remember  that  leucocytosis  occurs,  and  the  count 
varies  between  10,000  and  16,000. 

Remember  that  in  the  chronic  form  the  onset  is 
more  insidious. 

Remember  that  in  the  chronic  cases  periods  of 
attacks  of  pain,  tenesmus,  diarrhea,  with  mucus  and 
blood  in  the  stools  and  with  slight  fever,  alternate 
with  periods  of  constipation  and  apparent  good 
health. 

Remember  that  these  patients  suffer  from  indi- 
gestion, and  errors  in  diet  cause  a  dysenteric  attack. 

Remember  that  fatigue  or  sudden  chilling  of  the 
body  from  exposure  frequently  produces  an  attack. 

Remember  that  the  ameba  coli  is  present  in  the 
stools,  and  should  be  sought  for  in  suspected  cases. 

Remember  that  it  is  in  amebic  dysentery  that  liver 
abscess  is  exceedingly  common  and  should  be 
watched  for. 

Always  outline  the  upper  border  of  the  liver  daily. 


232  INFECTIOUS   DISEASES. 

as  the  abscess  is  usually  located  near  the  upper  sur- 
face and  causes  an  irregular  upward  curve  of 
hepatic  dullness. 

Remember  that  other  symptoms  of  liver  abscess 
are  fever,  sweat,  local  pain,  and  edema. 

Remember  these  abscesses  may  rupture  and  drain 
through  the  lung.  When  this  occurs,  the  sputum  is 
dark  and  contains  the  ameba. 

Treatment. 

Rest  in  bed  is  very  important  in  both  forms  of  the 
disease,  as  it  hastens  recovery. 

Diet  should  be  governed  by  the  severity  of  the 
intestinal  trouble.  In  the  acute  form  it  should  be 
liquid,  such  as  milk,  whey,  and  broth. 

Intestinal  antiseptics  are  used  on  the  theory  that 
ameba  require  the  presence  of  other  bacteria. 

Acetozone  given  by  mouth  and  also  in  enema  has 
accomplished  some  good. 

Bismuth  in  any  form  should  not  be  given  in 
amebic  dysentery.  h 

That  local  treatment  is  best  can  not  be  disputed. 
Of  all  drugs  used  locally,  quinin  is  best.  The  solu- 
tion of  quinin  should  be  1:5000  at  first,  then  in- 
creased to  1:2500,  and  later  further  increased  in 
strength  of  1:1000. 

If  the  following  method  of  injection  be  followed, 
better  results  will  be  obtained: 

The  patient  should  lie  on  his  back,  with  the  hips 
elevated,  so  that  gravity  will  assist.     From  1  to  2 


AMEBIC   DYSENTERY ^MEASLES.  233 

quarts  of  the  solution  should  be  used.  The  injec- 
tion should  be  given  slowly,  and  the  patient  should 
turn  from  side  to  side  during  the  injection,  so 
that  all  parts  of  the  colon  will  be  bathed  by 
the  solution.  The  enema  should  be  retained  for 
fifteen  or  twenty  minutes  if  iDossible.  When  the 
enema  causes  much  pain,  it  may  be  preceded  by  in- 
jection of  laudanum  and  starch  water.  Two  injec- 
tions daily  should  be  given.  For  the  severe  pain 
and  tenesmus  a  hypodermic  of  morphin  should  be 
given. 

Large  doses  of  ipecac  are  recommended  by  many, 
as  are  also  saline  injections  and  injections  of  ice 
water. 

Patients  should  not  be  allowed  cold  drinks  during 
acute  attacks,  and  hot  applications  to  the  abdomen 
often  give  great  relief. 

Measles. 

Remember  that  the  period  of  incubation  varies 
between  seven  and  fourteen  days. 

Remember  that  the  onset  is  usually  with  a  coryza. 
The  eyes  are  red  and  watery,  and  there  is  photo- 
phobia. 

Remember  that  the  troublesome  croupy  cough  be- 
gins early  and  continues  throughout  the  course. 

Remember  that  there  is  fever  on  the  first  day,  and 
that  the  peculiarity  of  the  fever  is  its  remission  on 
the  third. 

Remember  that  the  eruption  appears  on  the  fourth 
day,  beginning  on  the  face. 


234  INFECTIOUS    DISEASES. 

Remember  that,  as  a  rule,  there  will  be  patches  of 
skin  between  the  eruptions  that  will  be  of  normal 
color,  but  the  boundary  between  the  eruption  and 
the  healthy  skin  is  always  crescent  in  shape. 

Eemember  that  the  eruption  disappears  on  pres- 
sure, but  in  some  cases  hemorrhage,  or  petechia, 
occurs  into  the  skin  and  they  will  not  then  disap- 
pear. 

Remember  that,  while  there  may  be  slight  swell- 
ing of  the  cervical  Ijinph  glands  at  the  height,  it  is 
never  so  pronounced  as  in  scarlatina. 

Always  look  for  Koplik's  spots  on  the  mucous 
membrane  of  the  mouth.  They  occur,  as  a  rule,  on 
the  first  day  of  invasion,  and  consist  of  bluish-white 
specks  surrounded  by  bright-red  roseola.  While 
they  resemble  that  of  thrush,  they  have  not  the 
yellowish  center. 

Eemember  that  the  rash  fades  on  the  third  day, 
and  fine,  branny  desquamation  occurs  that  is  fre- 
quently overlooked. 

Eemember  that  lobular  pneumonia  is  exceedingly 
common,  and  usually  occurs  at  the  height  of  erup- 
tion or  beginning  of  desquamation.  Always  ex- 
amine chest  daily. 

Always  look  for  otitis  media,  because  it  is  com- 
mon in  measles  and  may  develop  mastoid  abscess. 

Never  be  in  too  great  haste  to  differentiate 
measles  and  smallpox;  it  frequently  requires  some 
time  for  distinctive  developments. 


MEASLES.  235 

Treatment. 

The  patient  should  be  put  to  bed  in  a  well- 
ventilated  room.  If  photophobia  be  severe,  the  room 
should  be  darkened  or  yellow  curtains  hung. 

The  diet  should  be  liquid  during  febrile  reaction. 
Milk  and  broths  are  best.  Care  in  selecting  a  diet 
is  necessary,  that  a  troublesome  diarrhea  is  not 
started.  Cathartics  should  be  used  sparingly  for 
the  same  reason.  The  best  is  castor  oil  with  2  or  3 
drops  of  turpentine  in  it. 

If  the  fever  is  high,  sponging,  or  the  warm  bath 
gradually  cooled,  is  excellent. 

Some  simple  fever  mixture  may  be  used,  as : 

B     Potassii   citratis    3  iv 

Tincturae    aconiti    TTL  x 

Spiritus  setheris  nitrosi    3  ij 

Syrupi  tolutani o  j 

Aquae    q.  s.  ad  §  ii  j 

Misce. 

Sig. :  Half  to  teaspoonful  every  two  hours  for  child  of  1 
to  2  years. 

Or: 

B.     Sodii   bromidi    gr.  1 

Spiritus  setheris  nitrosi 3  ij 

Liquoris  potassii  acetatis    .  .  q.  s.  ad  5  ii j 
Misce. 
Sig. :  Teaspoonful  every  two  hours  for  child  of  1  to  3  years. 

The  cough  should  be  treated  from  the  beginning 
of  the  attack.  The  fact  should  ever  be  kept  in  mind 
that  tuberculosis  very  frequently  follows  measles. 

Paregoric  may  be  added  to  either  of  the  fever  mix- 


236  INFECTIOUS    DISEASES. 

tures.     Codein  is  probably  better.     The  following 
combination  is  very  efficient: 

I^     Codeinae    phosphatis     gr.  ij 

Syrupi  ipecacuanhse   ,. 3  j 

Syrupi  pruni  virginiante    5  j 

Aquae   camphorae    q.  s.  ad  3  iij 

Misee. 

Sig. :   Teaspoonful  every  two  hours  for  child  of  6  years ; 
one-half  to  one-quarter  the  amount  for  younger  child. 

Or: 

IJ     Codeinae  phosphatis    gr-  ij 

Ammonii   carbonatis    gr.  xxy 

Syrupi    scillse    3  j 

Syrupi   pruni  virginianae    §  j 

Aquae   camphorae    q.  s.  ad  §  iij 

Misce. 

Sig.:   Teaspoonful  every  two  hours  for  child  of  6  years; 
one-half  to  one-quarter  the  amount  for  younger  child. 

Or: 

IJ     Pellet  aconitinae  amorphae   (Abbott)  aagr.  1,^34 
Sig. :  Dissolve  1  for  each  year  of  child's  age  and  1  extra 
in  3  ounces  of  water  and  give  teaspoonful  hourly  for  fever. 

"When  the  eruption  fails  to  come  out,  wrap  the 
child  in  blankets  wrung  out  of  hot  water  and  give 
hot  drinks.  During  convalescence  the  child  should 
be  given  careful  attention  and  protected  from  cold. 

Scarlet  Fever  (Scarlatina). 

Remember  that  the  mild  cases  of  angina  may 
spread  the  disease.  This  is  usually  the  way  epi- 
demics spread  in  schools. 

Remember  that  milk  is  responsible  for  many  epi- 
demics. 


SCARLET   FEVER.  237 

Remember  that  a  sudden  onset,  with  vomiting  and 
a  rapid  rise  in  the  temperature,  with  a  rapid,  wiry 
pulse,  is  very  characteristic  of  scarlatina  in  children. 
The  next  symptom  in  order  of  appearance  and  im- 
portance is  the  angina. 

Remember  that  the  lymph  glands  behind  the  angle 
of  the  jaw  are  enlarged  in  scarlatina. 

Remember  that  the  eruption  comes  early — usually 
by  the  second  day — begins  on  the  neck  and  chest, 
and  spreads  rapidly  all  over  the  body,  with  the  ex- 
ception of  certain  parts  of  the  face,  especially  the 
region  of  the  mouth  and  chin,  which  are  conspicuous 
by  their  pallor. 

Remember  that  there  is  a  uniform  blush  of  the 
skin,  and  the  eruption  is  punctate  and  of  a  deeper 
color.  There  is  no  intervening  healthy  skin,  and  no 
crescentic  arrangement  of  the  eruption,  as  seen  in 
measles. 

Remember  that  pressure  causes  blanching  of  the 
skin,  but  the  blush  quickly  returns  when  pressure  is 
removed. 

Remember  that  the  tongue  is  very  characteristic. 
On  the  first  and  second  days  the  tip  and  margins 
are  red,  while  the  center  is  covered  by  a  grayish- 
yellow  coating.  This  coating  disappears  after  the 
eruption  is  out,  and  the  tongue  now  appears  in- 
tensely red,  with  the  papillae  markedly  swollen  and 
raised,  producing  the  "raspberry"  or  "strawberry" 
tongue,  and  this  is  very  characteristic  of  scarlatina. 

Remember  the  following  points  in  differentiating 
scarlatina  and  measles: 


238  INFECTIOUS    DISEASES. 

1.  The  eruption  of  measles  occurs  first  in  the  face, 
and  is  especially  and  markedly  developed  here, 
while  in  scarlet  fever  the  neck  and  chest  are  first 
affected,  and  the  face,  under  all  circumstances, 
shows  less  eruption,  and  the  region  about  the  mouth 
is  particularly  free. 

2.  The  eruption  of  measles  occurs  on  the  fourth 
day,  while  in  scarlet  fever  it  may  occur  on  the  first 
and  never  later  than  the  second. 

3.  The  onset  of  scarlet  fever  by  vomiting  and  the 
severe  angina,  while  the  onset  of  measles  is  marked 
by  inflammation  of  the  mucosa  of  the  respiratory 
tract — coryza. 

4.  The  drop  in  the  temperature  on  the  morning  of 
the  second  day,  with  a  subsequent  rise  on  the  third 
or  fourth,  is  found  only  in  measles. 

5.  The  ''raspberry"  tongue  of  scarlet  fever  is 
rather  characteristic  of  it  and  is  not  seen  in  measles. 

Always  examine  the  urine  often  from  the  ninth 
day  until  the  sixth  week  for  the  appearance  of  signs 
of  nephritis.  This  is  the  most  common  complication, 
but  fortunately  it  rarely  becomes  chronic. 

Always  watch  the  ears  closely  for  otitis  media, 
as  it  very  frequently  occurs  in  scarlatina,  and,  if 
neglected,  will  lead  to  mastoid  disease. 

Remember  that  a  polyarthritis  often  follows  scar- 
latina, and  may  be  diagnosed  acute  inflammatory 
rheumatism,  but  the  ordinary  rheumatic  therapy 
will  have  no  effect  upon  it. 


scaklet  fever.  239 

Treatment. 

Prophylaxis.  The  patient  should  be  isolated  to 
prevent  dissemination.  As  to  the  contagious 
periods,  Forcheimer  may  be  quoted:  "The  disease 
is  not  contagious  during  the  period  of  incubation; 
little,  if  at  all,  during  the  period  of  invasion;  most 
contagious  during  the  period  of  eruption,  and  de- 
cidedly so  during  the  period  of  desquamation." 

The  patient  should  be  placed  in  a  well-ventilated 
room,  and  be  clad  in  light  flannel  gown  and  lightly 
covered. 

Diet  must  be  liquid.  Milk,  broths,  and  fresh  fruits. 
Water  should  be  given  freely. 

The  throat  and  mouth  should  be  washed  thor- 
oughly with  an  antiseptic  solution  to  protect  the  ear. 

The  following  is  a  good  gargle : 

IJ     Phenolis    gr.  xxx 

Glycerini     §  j 

Aquae  camphorae    §  j 

Potassii   cUorati    gr.  x 

Aquae    q.  s.  ad  5  vj 

Misce  et  fiat  solutio. 

Sig. :   Use  as  a  gargle  two  times  daily. 


Or: 


I^     Naphtolis    3  j 

Aquae    camphorae    3  iv 

Glycerini    §  j 

Aquae    rosae    §  ij 

Alcoholis     5  j 

Misce  et  fiat  solutio. 

Sig.:  Use  as  a  gargle  two  times  daily. 


240  INFECTIOUS    DISEASES. 

Or: 

IJ     Acidi  borici    3  ss 

Potassii   chlorati    3  ij 

Tincturse  ferri  chloridi    3  ij 

Syrupi  simplicis   5  ij 

Aquae    q.  s.  ad  §  iv 

Misce. 

Sig. :  Tablespoonful  every  two  hours  for  child  of  5  years. 

The  pharynx  and  posterior  nares  may  be  sprayed 
with  an  atomizer,  using  chloretone  inhalant  (P.  D. 
&  Co.),  or  5  grains  of  menthol  to  1  ounce  of  aboline. 
Peroxid  of  hydrogen  may  be  used,  either  pure  or 
combined  with  glycerin.  Careful  attention  to  the 
nose  and  throat  often  prevents  ear  complications. 

When  diphtheritic  patches  occur,  they  should  be 
wiped  off  with  a  swab  and  Loffler's  solution  applied. 
This  solution  consists  of: 

IJ.     Mentholis     3  iiss 

Toluolis     §  j 

Liquoris  ferri   chloridi    3  j 

or  creolin   TTl,  xxx 

Alcoholis  absoluti §  ij 

Misce  et  fiat  misturse.      Dispense  in  brown  bottle. 
Sig.:   Use  as  a  gargle  and  swab  the  throat  thoroughly. 

Fever  is  best  combated  by  hydrotherapy.  The 
cold  bath  of  typhoid  should  not  be  used.  In  light 
cases,  sponging  with  cool  water  or  water  and  vine- 
gar, with  cold  applied  to  the  head,  either  as  ice  bag 
or  towel  wrung  out  of  ice  water.  Where  the  tem- 
perature runs  high,  the  patient  may  be  put  in  tepid 
bath  and  the  temperature  gradually  reduced,  but 
never  below  75°  F. 


SCARLET    FEVER.  241 

Aconite,  either  as  the  tincture  irt  j-ttl  ij  every 
hour,  or  the  active  principle  aconitin  amorphous 
gr.  %34  every  fifteen  to  thirty  minutes,  may  be  given 
to  child  of  5  years  until  effect,  and  then  continued 
hourly.    The  following  is  a  good  fever  mixture: 

I^     Liquoris  ammonii  acetatis   3vj 

Potassii  chlorati  3  ss 

Tincturae  aconiti   Til,  xxx 

Syrupi  limonis    3  v 

Aquse    q.  s.  ad  §  iij 

Misee  et  fiat  solutio. 

Sig. :    Teaspoonful   every   two  hours,    and    may    be    given 
hourly  if  temperature  be  high. 

Quinin  and  phenacetin  are  very  effective  and  bene- 
ficial in  many  ways. 

IJ     Euquinini    ( Merck )    gr.  xxx 

Phenacetini     gr  v 

Syrupi  pruni  virginianse   5  vj 

Aquae  menthae  piperitae    .  .  .  .  q.  s.  ad  S  ij 
Misce  et  fiat  misturae. 

Sig. :  Teaspoonful  every  two  or  three  hours,   as  indicated, 
for  child  of  2  to  10  years. 

Delirium  and  muscular  twitching  call  for  sodium 
bromid.  Usually  ice  pack  to  the  head  is  sufficient, 
as  the  cerebral  congestion  from  the  fever  causes 
delirium. 

Cardiac  failure  calls  for  stimulants.  The  follow- 
ing is  very  efficient: 

IJ     Camphorse     3  ss 

Aetheris    3  v 

Misce. 

Sig. :   Inject  20  minims  subcutaneously. 

Whisky,  brandy,  or  aromatic  spirits  of  ammonia 
may  be  used. 


242  ESTFECTIOUS    DISEASES. 

Delayed  eruption  is  best  treated  with  atropin 
gr.  /^so  every  hour  until  physiologic  effect.  Warm 
baths  will  assist  also  in  bringing  out  the  eruption. 

Calcium  sulphid  and  urotropin  should  be  given 
throughout  the  disease. 

Calcium  sulphid  gr.  j-gr.  ij  should  be  given  when 
the  stomach  is  empty  to  prevent  the  action  of  HCl. 

Urotropin  gr.  %-gT.  v,  according  to  age,  is  given 
three  times  daily,  as  its  antiseptic  action  on  the 
urine  is  thought  to  protect  the  kidneys. 

Tincture  of  iodin,  glycerin,  and  ichthyol,  equal 
parts,  painted  over  the  enlarged  tender  glands  of 
the  neck  and  covered  by  rubber  tissue,  will  prevent 
suppuration  in  many  cases.  Unguentum  Crede  may 
also  be  used,  or  unguentum  hydrargyri  ammoniati. 
When  fluctuation  can  be  detected,  the  gland  should 
be  opened  and  drained. 

Nephritis.  As  a  preventive  measure  to  a  certain 
degree,  the  following  gives  good  results,  probably 
because  it  quiets  the  nervous  system: 

3     Chloral    hydratis    3  ij 

Sodii  bromidi    3  iij 

Syrupi  tolutani   5  j 

Aquse    q.  s.  ad  §  iij 

Misce. 

Sig. :  Teaspoonful  every  two  or  three  hours. 

Plenty  of  water  and  a  milk  diet  are  excellent  pro- 
johylactic  measure. 

The  urine  should  be  examined  daily  for  albumin. 
When  nephritis  develops,  the  treatment  in  no  way 
varies  from  that   outlined   under   acute   nephritis. 


SCARLET   FEVER MALARIA.  243 

During  the  period  of  eruption  and  desquamation  the 
body  should  be  rubbed  daily  with  some  oily  sub- 
stance, as  carbolated  vaselin  or  plain  olive  oil,  or 
where  there  is  much  itching  the  following: 

IJ     IMentholis    gr.  xx 

Olei  olivse    3  ij 

Adipis  lanse   §  i  j 

Misce  et  fiat  unguentum. 

Sig. :  Anoint  body  one  or  two  times  daily. 

A  warm  bath  should  be  given  daily  to  hasten  the 
desquamation.  The  body  should  be  thoroughly 
rubbed  during  the  bath  and  dried  with  a  tolerably 
rough  towel,  and  some  ointment  applied.  This  pre- 
vents the  scales  from  flying  and  lessens  the  danger 
of  spreading  the  disease. 

Convalescence  calls  for  tonics,  especially  those 
containing  iron.  There  is  none  better  than  elixir 
of  iron,  quinin,  and  strychnin,  and  essence  of  pepsin, 
equal  parts,  and  give  a  teaspoonful  three  times  daily. 

Malaria. 

Remember  that  the  disease  is  communicated  to 
the  well  solely  by  the  mosquito;  hence  the  impor- 
tance of  insisting  upon  a  malarial  patient  being  pro- 
tected from  the  mosquito. 

.  Remember  that  the  disease  may  remain  dormant 
for  a  variable  time  and  again  produce  the  clinical 
symptoms.  This  is  likely  to  be  thought  a  reinfec- 
tion, when  it  is  an  old  infection  that  has  not  been 
sufficiently  treated  to  be  cured.  There  are  a  number 
of  types: 


244  INFECTIOUS    DISEASES. 

1.  Intermittent  Fever. 

Remember  that  this  is  the  common  fever  and  ague, 
and  is  characterized  by  chill,  fever,  and  sweat,  fol- 
lowed by  a  total  remission  of  fever. 

Remember  that  the  chill  may  be  light  or  severe, 
and  begins  gradually.  The  temperature  rises  during 
the  chill. 

Remember  that  the  chill  may  be  overlooked,  espe- 
cially in  young  children,  but  the  lips  are  blue,  the 
face  is  pale  and  pinched,  the  skin  feels  cold,  and 
there  is  vomiting.  In  children  the  fever  may  cause 
nervous  sjTiiptoms  that  may  mislead  in  diagnosis. 

Remember  that  the  pulse  is  small,  hard,  and  fre- 
quent; the  hands  are  cold,  and  the  finger  nails  are 
blue. 

Remember  that  fever  follows  the  chill,  but  that 
the  temperature  begins  to  rise  even  prior  to  the 
chill  and  usually  reaches  its  maximum  at  the  end 
of  the  chill  or  very  soon  thereafter.  This  is  the 
period  of  circulatory  reaction  of  the  superficial  ves- 
sels, and  the  skin  becomes  red,  hot,  and  dry.  Thirst 
is  intense,  and  a  throbbing  headache  announces  the 
dilatation  of  the  cerebral  vessels. 

Remember  that  the  sweating  stage  is  the  last  in 
the  paroxysm,  and  affords  relief  of  all  the  symp- 
toms. The  amount  of  sweating  varies  from  a  moist 
skin  to  a  profuse,  drenching  the  clothes  and  bed. 

Remember  that  the  duration  of  the  paroxysm  va- 
ries from  eight  to  twelve  hours,  and  during  the 
paroxysm  the  spleen  is  enlarged. 


MALAEIA.  245 

Remember  that  herpes  labialis  occurs  more  fre- 
quently in  malaria  than  in  any  other  condition,  and 
is  very  suggestive  when  it  occurs. 

Remember  that  there  are  other  conditions  caus- 
ing chills,  fever,  and  sweat.  The  two  most  common 
are  tuberculosis  of  the  lungs  and  p^^emia. 

Remember  that  the  paroxysms  of  chill,  fever,  and 
sweat  found  in  malaria  are  periodical,  occurring 
with  marked  regularity,  while  the  paroxysms  occur- 
ring in  the  other  infections  are  irregular,  sometimes 
occurring  daily  and  then  less  frequently. 

Remember  that  the  blood  examination  will  show 
the  Plasmodium  in  malaria,  while  a  blood  culture 
will  give  a  growth  of  streptococci  in  septic  cases. 

Remember  that  in  the  nervous  chill  there  is  no 
fever,  or  at  most  the  rise  will  be  very  little,  while 
the  other  phenomena  of  malaria  will  be  absent. 

2.  Remittent  Fever. 

This  is  also  called  the  estivo-autumnal  fever,  but 
is  probably  best  known  as  bilious  fever. 

Remember  that  the  prodromal  symptoms  are  pro- 
nounced and  misleading.  They  are  malaise,  intense 
headache,  coated  tongue,  and  frequently  nausea  and 
vomiting.  The  vomiting  may  be  of  bilious  matter, 
and  there  may  be  jaundice,  with  tenderness  on  pres- 
sure over  the  liver. 

Remember  that  the  chill  is  less  severe  and  lacks 
the  characteristic  periodicity  of  intermittent. 

Remember  that  the  temperature  is  continually 
above  normal,  but  there  are  remissions  in  the  height. 


246  INFECTIOUS   DISEASES. 

Remember  that  the  blood  examination  shows  the 
small,  active,  motile,  hyaline  form  of  the  plasmodia, 
while  later  the  crescentic,  ovoid  bodies  may  be 
found. 

Remember  that  malarial  infection  of  any  type 
will  yield  when  the  patient  is  cinchonized,  but  don 't 
forget  that  there  is  a  difference  between  giving 
quinin  and  cinchonizing  a  patient. 

Remember  that  typhoid  and  remittent  malarial 
fever  is  frequently  confused,  but  the  following 
should  determine  the  question: 

1.  Plasmodium  found  in  the  blood  in  malaria. 

2.  Eruption  in  first  week  in  typhoid  fever. 

3.  Widal  reaction  of  agglutination  present  in  ty- 
phoid and  occurring  from  the  fifth  day  on. 

4.  Cinchonizing  patient  with  quinin  will  send  the 
temperature  to  normal  in  malaria;  no  effect  in 
typhoid. 

3.  Pernicious  Malaria. 

Remember  that  the  pernicious  types  may  not  be- 
gin with  a  chill  and  the  onset  may  be  sudden. 

Remember  that  there  are  two  types — comatose 
and  algid.  In  the  comatose  type  there  are  low,  mut- 
tering delirium,  skin  is  hot  and  dry,  temperature 
high,  and  may  terminate  fatally.  The  digestive  sys- 
tem bears  the  brunt  of  the  attack  in  the  algid  type. 
There  are  extreme  nausea,  vomiting,  collapse,  with 
coldness  of  the  extremities.  The  pulse  becomes 
small  and  feeble,  the  breathing  is  rapid  and  shallow. 


MALARIA.  247 

suppressed  urine,  colicky  pains,  purging,  and  great 
thirst. 

Remember  that  the  pernicious  forms  may  be  com- 
plicated by  paraplegia,  and  acute  ataxia  has  been 
described.  Multiple  gangrene  may  occur.  Orchitis 
has  occurred  in  some  cases. 

4-.   Chronic  Malaria. 

The  cachexia  is  the  most  prominent  symptom. 
It  is  caused  by  blood  changes.  Anemia  is  extreme, 
and  causes  breathlessness  on  exertion;  edema  of 
the  ankles.  The  spleen  is  enlarged  and  hard;  its 
border  may  extend  to  the  iliac  crest.  Some  cases 
are  jaundiced,  and  all  have  a  peculiar  yellow  color. 

Remember  that  leukemia  causes  an  enlarged 
spleen,  but  the  changes  in  the  blood  cells  are  very 
characteristic  in  leukemia,  and,  in  addition,  the  Plas- 
modium is  found  in  the  blood  in  malaria. 

Remember  that  intense  choleraic  form  occurs. 
The  purging  is  very  profuse  and  watery.  There  is 
fever  and  collapse,  and  death  may  occur. 

Remember  that  there  is  a  gastralgic  form,  in 
which  there  is  agonizing  epigastric  pain,  abdominal 
tenderness,  and  perhaps  diarrhea.  It  has  been  mis- 
taken for  appendicitis  by  surgeons. 

Remember  that  malaria  may  closely  simulate 
dysentery.  There  will  be  frequent,  mucoid,  bloody 
stools;  colicky,  abdominal  pains;  tenesmus,  and  pro- 
gressive emaciation. 

Remember   that  neuralgia  may  be   of  malarial 


248  INFECTIOUS    DISEASES. 

origin.    The  proper  administration  of  qninin  is  usu- 
ally very  efficacious  in  these  cases. 

Remember  that  hematuria  may  occur  in  any  ma- 
larial infection,  but  is  much  more  common  in  the 
tropics.  This  is  a  hemaglobinuria,  and  the  parasite 
can  always  be  found  in  the  blood.  It  is  doubtful  as 
to  quinin  either  causing  it  or  making  it  worse. 

Teeatment. 

Patients  known  to  be  malarial  should  be  pTotected 
from  mosquitoes,  so  that  the  infection  may  be  lim- 
ited. 

Calomel  as  a  cathartic  has  no  equal  in  beginning 
the  treatment. 

Vomiting  should  be  controlled  by  calomel  and 
cerium  oxalate. 

Quinin  is  the  specific  for  malaria,  but  its  action 
can  be  enhanced  by  proper  combinations. 

There  is  a  vast  difference  between  stopping  the 
paroxysms  of  malaria  and  a  cure. 

The  mixed  treatment  is  the  best.  The  following 
has  given  excellent  results  in  a  large  number  of 
cases: 

IJ     Codeinse  pliosphatis    gr.  % 

Quininse   hydrochloridi    gr-  iij 

Arseni  trioxidi    gr.  y^Q 

Eerri  ferrocyanidi    gr.  j 

Pulveris   camphorse    gr.  j 

Misce  et  fiat  capsula  No.  I.    Dentur  tales  doses  No.  XX. 

Sig. :  Capsule  every  three  hours. 

This  is  given  after  a  good  purge  with  calomel. 


MALARIA.  249 

For  children  and  those  unable  to  take  a  capsule  the 
following  is  good: 

IJ     Euquinini    ( Merck )    3  j 

Syrupi  pruni   virginianse    3  vj-3  viij 

Rub  up  the  euquinini  thoroughly  with  syrup. 

Codeinse  phosphatis   gr.  iss-gr.  iij 

Liquoris  potassii  arsenatis TT|.  Ix-Tl^  Ixs 

Aquae  menthae  piperitse    ...  .q.  s.  ad  §  iij 

Misce  et  fiat  misturse. 

Sig. :   Teaspoonful  every  three  hours.     Shake. 

For  the  pernicious  forms  quinin  must  be  given 
hypodermatically. 

R     Quininai  hydrochloridi   gr.  xxx 

Antipyrini     gr.  xx 

Aquae  destillatae    3  j 

Misce  et  fiat  solutio. 

Sig.:  Inject  10  minims  every  three  or  four  hours. 

Quinin  hydrobromid,  in  3-grain  doses,  dissolved 
in  20  minims  of  pure  warm  water  and  sterilized, 
makes  probably  the  best  method  of  administering 
quinin  hypodermatically.  In  injection  of  solution 
of  any  of  the  salts  of  quinin  it  should  be  made  deep 
into  the  muscle. 

Where  a  solution  of  quinin  is  to  be  given  per  os, 
the  following  affords  a  good  example.  Never  use 
any  flavoring  syrup,  as  it  keeps  the  bitter  taste  in 
the  mouth,  while  a  good  drink  of  water  in  a  plain 
solution  removes  all  the  bitterness. 

R     Quininse   hydrochloridi    3  iv 

Tincturse  ferri  chloridi   3  iv 

Aquae    q.  s.  ad  §  iij 

Misce. 

Sig. :  Teaspoonful  every  three  hours. 


250  INFECTIOUS    DISEASES. 

Where  there  exists  an  idiosyncrasy  against  quinin 
other  drugs  must  be  used. 

IJ     Methylene  blue   9  ij 

Arseni    trioxidi     gr.  ss-gr.  j 

Pulveris  myristicse   3  ij 

Misce  et  fiant  capsulte  No.  XX. 

Sig. :  Capsule  four  times  daily. 

Or: 

IJ     Tincturse   eucalypti    §  j 

Sodii  arsenatis    S^•^^ 

Acacise, 

Aquae  gaultherise aa  q.  s.  ad  5  ij 

Misce  et  fiat  emulsio. 

Sig.:  Teaspoonful  every  two  or  three  hours. 

The  treatment  of  malaria  should  be  continued  for 
at  least  two  weeks  after  the  subsidence  of  all  symp- 
toms if  the  Plasmodia  are  to  be  completely  eradi- 
cated. The  amount  of  quinin  given  should  be  re- 
duced. Three  grains  three  times  daily  are  sufficient, 
but  must  be  given  so  that  it  will  be  absorbed — best 
in  capsule,  followed  by  acid  drink,  as  lemonade  or 
dilute  muriatic  acid.  During  this  period  of  conva- 
lescence iron  should  be  given,  and  Blaud's  pill  can 
not  be  improved  upon.  Ferri  carbonatis  may  be 
given  in  the  quinin  capsule. 

In  chronic  malaria,  with  the  enlarged  hard  spleen, 
potassium  iodid  should  be  used  and  Fowler's  solu- 
tion should  be  pushed.  In  administering  Fowler's 
solution,  it  is  better  to  begin  with  a  small  dose — 
2  minims — three  times  daily  after  meals  and  in- 
crease 1  minim  every  third  day  until  puffy  eye-lids 
or  diarrhea  announce  complete  saturation,  when  the 


MALARIA — DIPHTHERIA.  ,  251 

dose  should  be  reduced  by  dropping  1  minim  every 
third  day  until  2  minims  are  taken  at  a  dose. 

Diphtheria. 

Remember  that  it  is  highly  contagious,  either  di- 
rectly from  sick  to  well  or  through  some  intervening 
body,  as  nurse,  physician,  or  articles  about  the  pa- 
tient. 

Remember  that  we  have  diphtheria  carriers,  as  in 
typhoid.  They  show  no  signs  of  infection,  yet  the 
germ  has  been  obtained  from  their  throats. 

Remember  that  milk  is  responsible  for  many  epi- 
demics, the  teats  of  the  cow  harboring  a  virulent 
organism. 

Remember  that  children  from  2  to  5  years  are 
most  susceptible. 

Remember  that  not  all  cases  that  have  a  mem- 
brane in  the  throat  have  diphtheria.  The  strepto- 
cocci often  cause  a  diphtheroid  condition  of  the 
throat,  but  the  clinical  symptoms  are  not  character- 
istic of  true  diphtheria. 

Remember  that  in  the  laryngeal  form  the  child  is 
usually  hoarse  at  night  and  has  a  brassy,  croupy 
cough. 

Remember  that  dyspnea,  becoming  extreme  as  the 
membrane  advances  until  eventually  cyanosis  and 
carbonic  acid  poisoning,  is  the  course  of  diphtheritic 
croup. 

Remember  that  otitis  media  is  frequent  in  diph- 
theria, and  in  the  nasal  form  the  eyes  may  become 
involved. 


252  INFECTIOUS    DISEASES. 

Remember  that  a  serous,  sanguinous,  or  bloody 
discharge  from  the  nose  that  excoriates  the  mucosa 
and  the  skin  is  very  suspicious  of  diphtheria. 

Remember  that  paralysis  of  the  soft  palate  and 
the  regurgitation  of  liquids  through  the  nose  is  very 
characteristic  of  diphtheria. 

Always  make  a  bacterial  examination  of  the 
throat,  as  the  presence  of  Klebs-Loffler  bacilli  makes 
it  diphtheria,  regardless  of  the  presence  or  absence 
of  a  false  membrane  or  other  clinical  signs. 

Remember  that  the  systemic  reaction  caused  by 
the  local  infection  produces  fatigue,  drowsiness,  pal- 
lor, coated  tongue,  anorexia,  dysphagia,  and  vomit- 
ing. There  may  be  a  chill,  but  more  often  chilliness, 
and  the  temperature  usually  rises  gradually  until 
it  reaches  102°  or  103°  F.,  remains  stationary  a 
couple  or  three  days,  then  declines  by  lysis,  and  rises 
again  from  the  fourth  to  the  seventh  day.  The 
pharynx  is  red,  edematous,  and  glistening.  A  gray- 
ish-white membrane,  changing  later  to  a  dirty-gray, 
may  be  seen  on  the  tonsils,  fauces,  or  posterior  wall 
of  the  pharynx. 

Remember  that  the  peculiarities  of  the  membrane, 
are  its  gradual  growth  until  it  covers  the  tonsils, 
faucial  pillars,  uvula,  and  palate;  and,  further,  that 
it  is  firmly  adherent,  so  that  when  removed  a  raw, 
bleeding  surface  is  left,  which  is  again  soon  covered 
by  a  membrane.    The  voice  has  a  ' '  nasal  twang, ' ' 

Remember  that  the  lymph  glands  at  the  angles  of 
the  jaw  are  enlarged  and  may  be  tender. 


DIPHTHERIA.  253 

Remember  that  the  membrane  may  be  absent,  and 
nothing  more  than  catarrhal  condition  of  the  throat 
be  present  on  inspection  and  the  patient  have  a 
cronpy  cough. 

Remember  that  in  some  cases  the  tonsils  are  cov- 
ered by  an  exudate  closely  resembling  that  seen  in 
follicular  tonsillitis,  and  no  true  membrane  be 
present. 

Remember  that  there  are  cases  in  which  the  tox- 
emia is  so  profound  that  the  patient  succumbs  be- 
fore local  lesions  occur. 

Remember  that  when  bacteriologic  examination 
can  not  be  made,  all  cases  of  "sore  throat"  and 
croup,  especially  if  there  is  swelling  of  the  lymph 
glands  at  the  angles  of  the  jaw,  must  be  regarded 
as  diphtheria. 

Treatment. 

Hygienic.  Confine  patient  to  a  room  free  of  car- 
pet, curtains,  and  superfluous  furniture.  Keep  the 
room  temperature  at  68°  F.  and  air  moistened  by 
kettle.  Good  ventilation  must  be  secured.  No  one 
but  the  nurse  and  the  doctor  in  the  room.  All  bed 
clothes  and  whatever  is  used  about  the  patient 
should  be  immediately  thrown  into  a  solution  of 
carbolic  acid. 

Local  treatment  consists  of  swabbing,  spraying, 
and  gargle — peroxid  of  hydrogen  full  strength,  car- 
bolic acid  1  to  3-percent  solution,  bichlorid  of  mer- 
cury 1:5000. 

A  very  excellent  method  is  the  application  of  95- 


254  INFECTIOUS    DISEASES. 

percent  phenol  by  swab  to  the  area  covered  by  the 
membrane,  and  repeat  once  daily,  making  a  thor- 
ough application. 

In  laryngeal  croup  a  steam  tent  may  be  arranged 
upon  the  bed,  so  that  the  air  breathed  by  the  child 
will  be  saturated  with  moisture.  When  signs  of 
obstruction  are  marked,  intubation  or  tracheotomy 
should  be  performed. 

Hot  applications  should  be  applied  to  the  neck  of 
children,  while  cold  should  be  used  in  adults. 

Diet  should  be  liquid — milk,  soups,  and  broths. 
Albumen  water  and  plain  water  should  be  used 
freely.  The  bowels  must  be  kept  open,  and  calomel 
in  fractional  doses  is  best. 

Sponging  may  be  used  to  reduce  the  fever  when 
the  temperature  is  high. 

Stimulants  should  be  used  when  indicated.  It 
should  never  be  forgotten  that  the  toxin  has  a  se- 
lective cardiac  action,  and  the  heart  must  be  closely 
watched. 

The  patient  should  be  kept  in  bed  and  quiet,  and 
all  excitement  avoided.  Atropin  sulphate  gr.  M.00- 
gr.  Veo,  adult  dose,  administered  hypodermatically 
should  be  used  at  the  first  sign  of  heart  weakening. 
Inasmuch  as  the  toxins  are  retained  in  the  body 
some  time  after  the  recovery,  the  child  should  be 
kept  in  bed  two  weeks  after  normal  temperature 
has  been  established. 

Specific  treatment  is  the  only  sane  and  rational 
way  to  treat.     Antitoxin  should  be  administered 


DIPHTHERIA EHEr:^L\TIC    FEVER.  255 

early  and  in  sufficient  doses.  The  earlier  tlie  anti- 
toxin is  given,  the  less  likely  to  have  complications, 
and  especially  of  the  heart.  One  should  make  it  a 
rule  to  give  it  in  cases  that  are  at  all  suspicious. 
Dose  enough  is  a  hard  c[uestion  to  decide,  because 
the  dosage  is  empirical.  Administer  4,000  or  5,000 
units,  and  repeat  in  t^venty-four  hours  if  no  signs 
of  the  membrane  loosening  at  the  border  and  the 
symptoms  do  not  improve.  Antitoxin  is  harmless, 
and  should  be  given  until  results  are  obtained. 

Rheumatic  Fever  (Inflammatory  Rheumatism). 

Remember  that  this  is  an  acute  infectious  disease, 
due  to  a  micro-organism  not  yet  isolated. 

Remember  that  exposure  to  cold  and  vet  is  more 
important  as  a  cause  than  heredity. 

Remember  the  close  relationship  that  exists  be- 
tween inflammatory  rheumatism  and  tonsillitis,  and 
frequently  an  apx3arent  tonsillitis  is  but  the  onset  of 
rheumatism. 

Remember  that  the  onset  is  usually  sudden,  vith 
rigor  or  chill  and  a  rise  of  temperature.  The  pulse 
is  soft  and  frequent,  usually  above  100. 

Remember  the  jprofuse  acid  sweat,  with  a  peculiar 
sour  odor. 

Remember  that  the  joints  soon  become  red,  swol- 
len, and  exc[uisitely  painful.  The  peculiarity  of  the 
joint  involvement  of  skipping  from  joint  to  joint  is 
characteristic  of  inflammatory  rheumatism. 

Remember  the  anemia.     No   other  acute  febrile 


256  INFECTIOUS    DISEASES. 

disease  causes  such  a  rapid  anemia,  which  accounts 
for  the  pallor. 

Remember  that  the  joint  involvement  is  rare  in 
children,  and  cardiac  complication  exceedingly 
common. 

The  ''growing  pains"  of  childhood  are  rheuma- 
tism, and  should  be  carefully  looked  after. 

Remember  that  arthritis  occurring  in  septico- 
pyemia is  fixed,  and  few  joints  involved.  The  fever 
is  more  distinctly  intermittent. 

Remember  that  in  acute  osteomyelitis  the  epiphy- 
sis is  the  seat  of  the  trouble,  and  the  joint  is  not  in- 
volved, while  the  local  and  constitutional  symptoms 
are  more  severe. 

Remember  that  gonorrheal  arthritis  is  not  migra- 
tory. The  joints  involved  are  more  apt  to  be  the 
knee,  sternoclavicular,  or  vertebral  joints,  and  the 
urethral  discharge  of  the  male  or  vaginal  discharge 
of  the  female  should  be  examined  for  the  gonococci. 

Remember  that  an  arthritis  deformans  may  be- 
gin with  an  acute  inflammation  of  joints  and  fever. 
It  is  usually  the  smaller  joints  that  are  involved, 
but  in  many  cases  it  will  require  time  to  differen- 
tiate. When  the  acute  symptoms  pass  in  arthritis 
deformans  we  find  joint  changes  with  periarticular 
thickening,  while  in  inflammatory  rheumatism  there 
are  no  permanent  joint  changes. 

Remember  that  acute  rheumatism  attacking  the 
joints  of  the  spine  may  closely  simulate  meningitis, 
but  the  severe  headache,  pupillary  changes,  hyper- 
esthesia, and  Kernig's  sign  are  absent. 


EHEUMATIC    FEVER.  257 

Remember  that  during  the  course  of  acute  rheu- 
matic fever,  cerebral  rheumatism  may  develop, 
marked  by  rapid  rise  of  temperature — 106°  to  108° 
F. — rapid  small  pulse,  nystagmus,  vomiting,  spastic 
paralysis,  strabismus,  and  wild  delirium.  This  is  a 
very  serious  condition,  which  may  terminate  fatally. 

Treatment. 

The  patient  should  be  dressed  in  light  flannel 
gown,  and  confined  to  his  bed  between  blankets. 
The  inflamed  joints  should  be  wrapped  with  cotton 
and  bandaged. 

Diet  should  be  liquid  and  light.  Milk  is  best,  and 
to  it  should  be  added  a  little  bicarbonate  of  soda. 
Broths  may  be  used,  also  farinaceous  foods,  but 
meat  should  not  be  allowed.  Lemonade  should  be 
freely  given. 

Hyperpyrexia  must  receive  prompt  and  vigorous 
treatment  to  save  life — the  cold  bath  or  cold  applied 
along  spine  by  rubbing  with  a  piece  of  ice.  When 
the  temperature  is  reduced,  there  is  great  likelihood 
of  its  rising  again.  Pain  may  be  so  severe  as  to 
require  hypodermic  of  morphin.  Codein  gr.  %  hourly 
usually  gives  relief. 

Sodium  salicylate  for  the  cure  of  inflammatory 
rheumatism  is  almost  universally  used.  Salicylic 
acid  is  often  used,  but  its  irritating  effect  upon  the 
stomach  has  lessened  its  general  use.  Strontium 
salicylate  is  used  and  highly  recommended.  All 
these  salts  should  be  given  in  10  to  15-grain  doses, 


258  INFECTIOUS   DISEASES. 

and  for  the  first  twenty-four  to  forty-eight  hours 
should  be  repeated  often  enough  so  that  from  1  dram 
to  IVi  drams  are  taken  in  twenty-four  hours.  The 
important  thing  is  not  the  quantity,  but  the  complete 
saturation  of  the  patient,  which  is  manifested  by 
buzzing  in  the  ears.  The  drug  should  then  be  re- 
duced by  lengthening  the  interval.  An  alkali  should 
be  combined  with  the  salicylate  treatment — either 
sodium  or  potassium  bicarbonate,  or  potassium 
citrate.    The  following  have  given  good  service: 

T^     Sodii  salicylatis    3  v 

Potassii   bicarbonatis    3  iiss 

Vini  colchici    3  iij 

Aquse  menthse  piperitse q.  s.  ad  §  iv 

Misce. 

Sig. :    Teaspoonful   every   two  hours   for    two    days,    then 
every  three  hours. 

Or: 

IJ     Aeidi  salicylatis, 

Potassii  acetatis    aa  3  iss 

Antipyrini    3  ij 

Syrupi   simplicis    3  iss 

Aquse  bullientis    5  vj 

Misce. 

Sig.:  Tablespoonful  every  three  hours. 

Or: 

IJ     Antipyrini    gr.  xx 

Sodii  salicylatis   3  ij 

Syrupi  sarsaparillae  compositae B  iij 

Aquse  menthse  piperitse    ...  .q.  s.  ad  §  vj 
Misce. 
Sig.:   Tablespoonful  every  three  hours. 

Or: 

^     Asperini    3  ij 

Fiant  capsulae  No.  XII. 

Sig.:   Capsule  every  two  or  three  hours. 


KHEUMATIC    FEVER.  259 

The  following  is  the  best  for  local  application,  as 
it  gives  prompt  relief: 

IJ     Magnesii  sulphatis 3  Jj 

Phenolis    3  j 

Aquae  bullientis    O  j 

Misce. 

Sig. :  Envelop  the  joint  with  cotton  lightly  squeezed  out 
of  this  solution,  cover  with  dry  cotton,  and  apply  roller 
bandage  lightly. 

It  is  essential  that  the  salicylates  be  kept  up  in 
smaller  doses  for  some  time  after  temperature  is 
normal  to  prevent  relapse. 

Convalescence.  The  administration  of  iron  for 
anemia — the  elixir  of  iron,  quinin,  and  strychnin 
(U.S.  P.)— is  excellent. 


CHAPTER  Xn. 

CONSTITUTIONAL  DISEASES. 

Arthritis  Deformans. 

Remember  that  this  is  an  affection  in  which  pro- 
found changes  occur  in  the  joint,  and  these  changes 
are  not  only  chronic,  but  progressive. 

Remember  that  in  this  condition  there  is  no  uni- 
formity in  the  mode  of  onset.  Some  cases  have  an 
acute  onset,  with  fever;  red,  swollen,  and  tender 
joints,  so  closely  resembling  acute  rheumatism  that 
a  positive  diagnosis  will  be  impossible  during  this 
stage. 

Remember  that  in  acute  rheumatism  the  tendency 
is  to  a  complete  restoration  of  the  joint  function, 
while  in  arthritis  deformans  the  tendency  is  always 
toward  joint  destruction,  and  each  attack  further 
impairs  the  action  of  the  joint. 

Remember  that  the  small  joints  of  the  hand  and 
feet  are  the  first  to  be  attacked. 

Remember  that  in  an  acute  attack,  pain,  limita- 
tion of  movement,  and  swelling  of  the  joints  are 
present.  The  intensity  of  the  pain  is  of  no  aid  in 
prognosis.  First,  the  characteristic  of  the  pain  is 
that  it  is  spontaneous,  coming  when  the  joints  are 
at  complete  rest;  often  made  worse  by  the  warmth 
of  the  bed.  Second,  it  is  not  shifting  like  that  seen 
in  rheumatic  fever.     Third,  muscular  cramp,  due 

260 


ARTHRITIS    DEFORMANS.  261 

to  the  spasmotic  contraction  of  the  atrophied  mus- 
cles, thus  increasing  tension  and  pressure  on  the 
inflamed  joint. 

Remember  that  swelling  is  a  very  early  manifes- 
tation of  the  disease.  The  swelling  is  fusiform,  due 
to  the  thickening  of  the  capsule  of  the  joint.  The 
atrophy  of  the  intervening  muscles  causes  the  fusi- 
form appearance  of  the  joints  to  be  more  pro- 
nounced. The  large  as  well  as  the  small  joints  show 
this  fusiform  appearance. 

Remember  that  muscular  atrophy  occurs  in  all 
cases,  and  is  marked  by  its  progressiveness,  advanc- 
ing pari  passu  with  the  joint  lesion- 
Remember  that  in  many  cases  the  axillary  and  in- 
guinal glands  are  swollen. 

Remember  that  the  pigmentation  of  the  skin  is  a 
prominent  sign  in  many  cases.  It  occurs  on  the  fore- 
head, temples,  face,  and  neck.  The  tints  vary,  but 
the  most  common  are  lemon,  orange,  or  citron  color. 
The  patches  have  a  luster  varying  with  the  angle 
of  reflected  light. 

Remember  that  a  rapid  pulse,  having  no  relation 
to  the  fever,  is  of  considerable  value  in  diagnosis. 

Remember  that  the  symmetry  of  joints  involved  is 
very  significant,  while  the  large  number  of  joints 
involved  and  the  absence  of  any  tendency  to  casea- 
tion exclude  tuberculosis  in  the  diagnosis. 

Remember  that  Heberden's  nodes,  when  present, 
are  found  on  the  sides  and  ends  of  the  distal 
phalanges,  especially  of  the  fingers,  but  sometimes 


262  CONSTITUTIONAL   DISEASES. 

of  the  toes.  When  found,  they  are  of  prognostic 
value,  as  the  large  joints  very  rarely  become  in- 
volved, and  these  nodosities  are  said  to  be  promises 
of  long  life. 

Remember  that  joint  distortion  is  characteristic, 
and  due  to  exostoses  or  outgrowths  of  bony  sub- 
stances that  lock  the  joint. 

Treatment. 

Rest  during  an  acute  attack  is  imperative,  and, 
owing  to  rheumatic  simulation  at  this  stage,  the 
salicylates  should  be  given. 

Massage  should  not  be  attempted  with  an  acutely 
inflamed  joint,  but  it  is  clearly  indicated  after  this 
subsides.  When  carefully  and  perseveringly  carried 
out,  it  is  beneficial. 

Diet.  Plenty  of  good,  nourishing  diet  should  be 
given.  There  is  not  an  article  of  diet  that  is  known 
to  aggravate  it. 

Baths.  Hot  baths  are  excellent  and  a  course  at 
Hot  Springs,  Arkansas  or  Virginia,  will  often  be 
very  beneficial. 

Medicinal.  Fowler's  solution  of  arsenic,  given 
in  3  to  5-drop  doses,  has  given  good  results  in  some 
cases.  Guaiacol  carbonate  gr.  v-gr.  xv  daily  and 
rapidly  increased  gives  good  results,  and  its  good 
effect,  as  well  as  that  of  arsenic,  appears  to  be  en- 
hanced if  an  iodid  be  combined.  The  iodid  of  iron 
may  be  given,  or  a  saturated  solution  of  sodium 
iodid,  10  to  15  drops  in  milk,  an  hour  after  meals. 


ARTHRITIS   DEFORMANS GOUT.  263 

Superheated  air  to  the  affected  joints  by  means  of  a 
hot-air  apparatus  gives  good  results  in  many  cases. 

Gout. 

Remember  that  gout  is  a  nutritional  disorder,  and 
the  arthritis  is  due  to  the  deposit  of  sodium  biurate 
from  the  blood,  which  is  surcharged  with  an  excess 
of  uric  acid. 

Remember  that  the  use  of  fermented  liquors  and 
little  exercise  is  responsible  for  a  large  majority  of 
the  cases. 

Remember  that  gout  and  arteriosclerosis  usually 
coexist. 

Remember  that  the  following  are  the  premonitory 
signs  of  an  attack  of  acute  gout :  twinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  restlessness  at 
night,  irritability  of  temper,  and  dyspepsia,  with 
scant,  highly  colored  and  acid  urine  that  deposits 
urates  on  cooling. 

Remember  that  the  announcement  of  the  onset  is 
by  severe,  vise-like  pain,  occurring  in  the  metatarso- 
phalangeal articulation  of  the  big  toe — most  com- 
monly the  right.  The  attack  is  usually  nocturnal, 
gradually  subsiding  with  approach  of  day.  The 
joint  swells  rapidly,  the  tissues  become  edematous, 
and  the  skin  is  hot,  tense,  and  shiny.  Fever  is 
present. 

Remember  that  the  subsidence  of  the  attack  by 
morning,  to  recur  again  on  the  succeeding  night,  is 
markedly  characteristic  of  acute  gout. 


264  CON'STITUTIONAL   DISEASES. 

Remember  that,  notwithstanding  the  swollen, 
edematous  condition  of  the  joint,  it  never  goes  on 
to  suppuration,  but  gradually  subsides  and  the  skin 
desquamates. 

Remember  that  the  deposit  increases  with  each 
succeeding  attack  until  the  joint  is  swollen,  irregu- 
lar, and  deformed. 

Remember  that  the  urates  are  deposited  in  the 
cartilages  of  the  ears,  along  the  tendons,  and  in  the 
bursse,  and  may  be  felt  as  tophi  in  the  ears. 

Remember  that  severe  cramps  in  the  muscles  of 
the  calf,  abdomen,  or  thoracic  regions  occur  in  the 
chronic  form. 

Remember  that  in  gouty  subjects  severe  gastro- 
intestinal catarrh,  with  pain  and  diarrhea,  migraine, 
sciatica^  and  various  other  neuralgias,  often  take 
the  place  of  the  ordinary  acute  type. 

Burning  sensation  and  itching  of  the  feet  at  night, 
and  skin  lesions,  such  as  eczema,  is  a  frequent  com- 
plaint of  patients  with  gouty  diathesis. 

Remember  that  the  family  history  and  occupa- 
tion are  exceedingly  important  factors  in  arriving 
at  a  diagnosis. 

Remember  that  there  is  a  moderate  leucocytosis 
during  an  acute  attack  of  gout. 

Remember  that  there  are  some  conditions  closely 
allied  to  gout,  but  are  classed  as  lithemia.  There 
are  various  symptoms  grouped  under  this  heading, 
as  indigestion,  vertigo,  headache,  nervous  irritabil- 
ity, tingling  and  a  sense  of  numbness,  and  a  slow 


GOUT.  265 

pulse,  with  increased  tension  and  a  sharp  accentua- 
tion of  the  aortic  second  sound. 

Treatment. 

Acute  Attack.  The  first  thing  to  be  done  is  to  re- 
lieve the  pain.  The  extremes  of  temperature — cold 
and  hot — should  never  be  applied;  necrosis  is 
thus  encouraged.  The  joint  should  be  kept  quiet 
and  wrapped  in  cotton  or  compress  wrung  out  of 
water  at  the  room  temperature,  or  gauze  out  of  the 
following  solutions  may  be  applied:  equal  parts  of 
chlorofom  and  olive  oil,  or  oil  of  gaultheria,  to  which 
may  be  added  the  tincture  of  opium  in  the  ratio  of 
1  to  10.    The  following  is  good: 

IJ     Tincturse  opii    3  v 

Olei  gaultheriae   5  j 

Chloroformi   5  iss 

Misce  et  fiat  solutio. 

Sig. :  Paint  the  joint  several  times  daily.  Shake  well. 

Or: 

IJ     Estracti  belladonnae    gr.  xlv 

Extract!  opii  gr.  v-gr.  xv 

Unguenti  ichthyolis,   10-percent.  .  . .  5  j 

Misce  et  fiat  unguentum. 

Sig.:  Apply  two  times  daily. 

Or  gauze  out  of  a  saturated  solution  of  Epsom 
salts  applied  locally. 

Medication.  Colchicum  appears  to  be  the  favor- 
ite, but  should  be  administered  cautiously,  and 
should  not  be  continued  indefinitely.  The  active 
principle,  colchicin  gr.  %oo-gr.  Vso,  combined  with 
codein  phosphate  gr.  ^,  administered  every  one  or 


266  CONSTITUTIONAL   DISEASES. 

two  hours  until  diarrhea,  nausea,  etc. — the  symp- 
toms of  poisoning — when  it  should  be  administered 
less  frequently,  is  excellent.  The  bowels  should  be 
opened  freely  with  saline  laxative.  Potassium  iodid 
in  stubborn  cases  is  good. 

IJ     Potassii   iodidi    gr.  Ixxv 

Tincturse  colchici    3  iiss 

Aquse  destillatse    §  v 

Sig. :  Tablespoonful  in  glass  of  water  after  meals. 

Sodium  salicylate  is  preferred  by  many  in  15-grain 
doses  four  times  daily  to  adult  man. 

For  the  uric  acid  condition,  as  well  as  chronic 
gout,  that  medication  which  will  assist  in  holding 
urates  in  solution  is  the  best.  The  disodium  phos- 
phate appears  to  be  the  important  element  in  dis- 
solving urates,  and  the  administration  of  calcium 
salt,  preferably  the  carbonate,  protects  this  sodic 
phosphate  and  thus  assists  in  the  solution  of  the 
urates.     This  may  be  prescribed  as  follows: 

IJ     Calcil   carbonatis    gr.  x 

Lithii  carbonatis    gr.  j 

Colchieini     gr.  1,^qq 

Pulveris  aromaticse    gr.  x 

Misce  et  fiat  pulvere  No.  I,    Dentur  tales  doses  No.  L. 

Sig.:  Powder  every  three  hours  in  acute  conditions;    three 
times  daily  in  chronic  or  lithemic  conditions. 

These  patients  must  drink  plenty  of  water, 
whether  it  be  acute  or  chronic  condition.  The  alka- 
line mineral  waters  are  best. 

Exercise  must  be  taken,  even  in  acute  cases,  just 
as  soon  as  they  are  able  to  be  up. 

Diet.    Most  of  these  patients  eat  too  much.    The 


GOUT DIABETES    MELLITUS.  267 

amount  of  food  should  be  reduced.  Plenty  of  fresh 
vegetables  and  fruits  should  be  taken.  Meats  are 
allowable.  Fats  and  carbohydrates  should  form  a 
large  part  of  the  diet,  especially  the  fats. 

Lithemic  patients  should  be  given  potassium  iodid 
at  intervals  to  assist  in  elimination. 

Diabetes  Mellitus. 

Remember  that  not  all  cases  which  show  sugar  in 
the  urine*  are  diabetics.  The  following  three  factors 
must  be  true  in  all  cases  of  diabetes : 

1.  The  form  of  sugar  in  the  urine  must  be  grape 
sugar. 

2.  It  must  be  found  for  a  long  period  of  time — for 
weeks,  months,  or  even  years. 

3.  The  excretion  of  sugar  must  take  place  after 
the  ingestion  of  a  moderate  amount  of  carbohy- 
drates. 

Remember  that  a  slight  trace  of  sugar  is  common 
in  obese  persons. 

Remember  that  the  two  important  etiologic  fac- 
tors that  produce  diabetes  are: 

1.  Pronounced  nervous  derangement;  either  func- 
tional— as  worry,  mental  shock,  or  some  severe  ner- 
vous strain;  or  organic  lesion — as  disease  of  the 
spinal  cord  or  brain,  or  injury  in  the  region  of  the 
floor  of  the  fourth  ventricle. 

2.  Disease  of  the  pancreas,  leading  to  the  destruc- 
tion of  the  cells  of  the  islands  of  Langerhans — most 
frequently  caused  by  chronic  pancreatitis,  and  it  is 


268  CONSTITUTIOXAL    DISEASES. 

throTigli  this  condition  that  gallstones  become  an 
etiologic  factor. 
Remember  that  urinalysis  reveals: 

1.  Large  increase  in  the  amount  of  urine  for 
twenty-four  hours. 

2.  High  specific  gravity. 

3.  Pale  color  and  sweetish  odor. 

4.  Acid  reaction. 

5.  Sugar  is  present. 

6.  Albumin  usually. 

Remember  the  diabetic  tabes — a  peripheral  neuri- 
tis, with  lightning  pains  in  the  legs  and  loss  of  knee- 
jerk.  The  patient  has  the  ^'steppage  gait"  seen  in 
arsenical  and  alcoholic  neuritic  paralysis. 

Remember  that  a  patient  complaining  of  exces- 
sive thirst,  inordinate  appetite,  and  frequent  mictu- 
rition calls  for  an  examination  of  the  urine  for 
sugar. 

Remember  that  the  tongue  is  dry,  glazed,  and  red, 
and  the  mouth  is  dry.  The  gums  are  swollen,  and 
constipation  is  the  rule.  The  skin  is  dry,  no  sweat- 
ing unless  coexisting  phthisis  be  present,  furuncu- 
losis  is  common,  and  general  pruritus  may  be  very 
distressing. 

Remember  the  coma  that  develops  in  these  cases, 
due  probably  to  acetone,  and  usually  terminates 
fatally. 

Remember  that  fraud  is  often  practiced,  and  cane 
sugar  has  been  found  in  the  urine. 

Remember  that  gangrene  may  occur,  due  to 
arteriosclerosis. 


DIABETES    MELLITUS.  269 


TrEATMEjSTT. 


Diet.  The  first  thing  is  to  determine  the  amount 
of  sugar  excreted.  The  next  step  is  to  cut  off  all 
forms  of  carbohydrates  and  try  to  render  the  pa- 
tient aglycosuric.    The  following  outline  will  assist: 

Breakfast.  Tea  or  coffee,  §  vj ;  beefsteak  or  mut- 
ton chops  without  bone,  or  boiled  ham,  o  iv ;  one  or 
two  eggs. 

Lunch.  Cold  roast  beef,  5  vij ;  celery,  fresh  cucum- 
bers, or  tomatoes,  with  vinegar  and  olive  oil,  5  ij ; 
pepper  and  salt  to  taste;  water,  5xv;  coffee,  §ij, 
without  milk  or  sugar. 

Supper.  Clear  bouillon,  §  x;  roast  beef,  §  vij;  but- 
ter, 5  iij ;  green  salad,  5  ij,  with  vinegar,  3  ij,  and 
olive  oil,  o  vj ;  water,  §  xv. 

One  or  two  raw  eggs  may  be  given  at  bedtime  and 
water,  §  xv. 

The  amount  of  sugar  in  the  urine  will  drop,  but, 
should  a  small  amount  continue,  it  is  best  then  to 
have  a  ' '  fast  day, ' '  when  the  patient  takes  no 
nourishment  for  twenty-four  hours,  when  it  will  be 
found  that  the  patient  is  not  excreting  sugar.  The 
diet  should  be  carefully  arranged  for  each  indi- 
vidual case. 

Skin.  Baths  should  be  taken  frequently.  Warm, 
or  even  cold  if  the  patient  is  robust.  Some  carbol- 
ized  soap  should  be  used  to  wash  the  skin.  Flannel 
should  be  worn. 

Light  exercise  or  massage  should  be  used,  and  all 
worry  should  be  avoided  and  a  quiet,  even  life  lived. 


270  CONSTITUTIONAL   DISEASES. 

The  alkaline  mineral  waters  should  be  used  freely. 
From  3  to  6  ounces  of  Vichy  may  be  drunk  half  an 
hour  before  each  meal,  or  Apollinaris  may  be 
ordered  in  much  larger  quantities. 

Medicinal.  Opium  is  the  only  drug  that  is  worthy 
of  trial.  It  should  be  borne  in  mind  that  diabetics 
have  a  great  tolerance  for  it.  Codein  may  be  used, 
and,  as  it  is  less  constipating,  is  preferable.  Codein 
in  Yo-grain  doses  should  be  given  three  times  daily 
and  gradually  increased  until  4  or  5  grains  are 
taken. 

Opium  may  be  exhibited  in  many  ways,  as: 

B     Extract!  opii   gr.  xv 

Extract!  gentianse    q.  s. 

M!sce  et  fiat  massa.    Divide  in  pilulse  No.  XXX. 
Sig.:  3  to  12  pills  daily. 

Or: 

IJ     Extract!  opii   gr.  ss-gr.  j 

Extract!   belladonnse    gr.  S3 

Sacchari  lactis    gr.  v 

Misee  et  fiant  pulveres,    Dentur  tales  doses  No.  XXV. 

Sig.:  3  powders  daily. 

Arsenic  is  very  useful  in  many  cases.  It  may  be 
added  to  either  of  the  above  mixtures,  or,  better,  it, 
may  be  given  as  Fowler's  solution,  gradually  in- 
creasing the  dosage  until  saturation. 

Coma.  There  is  nothing  that  equals  venesection 
and  withdrawal  of  blood,  and  replacing  it  with  a 
1  or  2-percent  solution  of  sodium  bicarbonate  in  nor- 
mal salt  solution ;  1  or  2  pints  may  be  run  into  a  vein 
every  three  or  four  hours  if  necessary.    As  a  rule, 


DIABETES   MELLITUS.  271 

this  is  only  a  temporary  relief,  and  there  is  recur- 
rence and  death. 

Remember  that  by  administering  sodium  bicar- 
bonate at  frequent  intervals  it  may  be  possible  to 
postpone  an  attack  of  coma,  which  is  an  acidosis. 


CHAPTER  XIII. 
GENERAL  CONSIDERATIONS. 

Physician  and  Patient. 

One  of  the  most  essential  things  is  the  patient's 
confidence,  and  tliis  can  not  be  obtained  by  lond, 
boisterous  talking,  scolding,  fault-finding,  or  undue 
jocularity.  On  the  other  hand,  undue  timidity  or 
lack  of  self-confidence  is  equally  bad.  The  patient 
must  be  in  complete  ''en  rapport"  with  the  exam- 
iner if  the  most  is  to  be  accomplished. 

In  no  other  field  is  it  more  important  to  have  ac- 
curate knowledge  of  anatomy.  It  is  essential  that 
the  examiner  be  familiar  with  regional  anatomy — 
know  the  location  and  size  of  the  organs  in  health 
and  their  physiological  variations  before  any  accu- 
rate idea  can  be  had  of  pathological  conditions. 

The  examiner  must  be  alert,  and  use  all  his  per- 
ceptive faculties.  Often  observations  of  a  patient 
during  conversation  give  very  definite  information. 

It  is  essential  that  the  physical  examinations  be 
conducted  in  a  routine  manner.  More  errors  of  diag- 
nosis come  from  the  want  of  system  than  from  the 
lack  of  knowledge. 

Never  attempt  to  make  a  physical  examination 
through  the  clothing.  It  is  impossible  to  elicit 
physical   signs    through   heavy   clothing,    starched 

272 


PHYSICIAN   AND    PATIENT.  273 

linen,  or  tlie  corset,  while  the  crackling,  friction 
sounds  of  certain  fabrics  will  obscure  auscultation. 

Remember  that  careful  study  in  the  post-mortem 
room  is  essential  to  good  work  at  the  bedside.  Fre- 
quent study  of  mistakes  is  always  beneficial. 

Be  thorough  in  physical  examination,  but  that 
does  not  mean  that  you  should  be  rough.  There  is 
nothing  else  that  will  so  quickly  secure  complete 
co-operation  of  the  patient  as  gentle  manipulation. 
This  can  be  done  only  by  taking  plenty  of  time, 
with  the  patient  in  an  accessible  position,  and  know 
what  you  are  trying  to  do. 

Never  mistake  a  guess  for  a  diagnosis.  These 
"snap"  diagnoses  are  only  guesses,  and  have 
J:)rought  more  disappointment  than  glory,  but,  if 
only  the  physician's  reputation  suffered,  it  would 
not  be  so  bad. 

Always  obtain  a  history,  not  only  of  the  mode  of 
onset  of  the  present  ailment,  but  the  past  complaints 
and  of  the  family,  especially  of  any  fatal  illness  of 
the  family.  This  will  give  a  clew  as  to  the  inherited 
tendencies  of  the  patient. 

Where  a  patient  is  confined  to  his  bed,  always 
note  his  posture  in  bed.  Where  the  attitude  is  lax 
and  his  position  controlled  by  gravity,  and  he  re- 
mains in  cramped  and  uncomfortable  postures,  such 
a  patient  is  very  weak,  helpless,  or  unconscious,  and 
is  said  to  assume  the  passive  position.  On  the  other 
hand,  the  less  the  general  feelings  are  affected,  the 
more  natural  and  unconstrained  will  be  his  position. 


274  GEXEEAL    COXSIDEEATIONS. 

Again,  a  patient  with  respiratory,  cardiac,  or  renal 
affections,  associated  witli  much  dyspnea,  can  not 
lie  upon  his  back,  because  the  accessory  muscles  of 
respiration  can  be  used  to  advantage  only  in  sitting 
posture. 

Patients  are  constrained  to  lie  upon  one  side  be- 
cause of  unilateral  affection  of  the  thoracic  viscera. 
The  patient  usually  lies  upon  the  abdomen  in  colic, 
cardialgia,  and  sometimes  intestinal  obstruction, 
while  in  peritonitis  the  abdomen  is  tender  and  the 
patient  lies  upon  his  back. 

The  state  of  nutrition  should  be  noted.  Chronic 
conditions  are  usually  associated  with  emaciation. 
Edema  of  the  skin  and  subcuticular  fat  should  be 
distinguished.  Eemember  that  edema  pits  on  pres- 
sure with  the  thumb  and  the  depression  very  slowly 
disappears. 

Observe  the  color  of  the  skin.  Note  whether  there 
be  pallor.  Don 't  forget  the  peculiar,  waxy  pallor  of 
nephritis.  Again,  cyanosis  of  the  skin  and  mucous 
membranes  denotes  either  an  insufficient  oxidation 
or  an  obstruction  to  the  venous  return. 

Remember  that  jaundice  is  significant  of  biliary 
trouble.  The  darker  shades  signify  an  obstruction 
of  long  duration. 

Many  of  the  serious  diseases  cause  undue  pigmen- 
tation of  the  skin.  Thus,  melanosarcoma  is  accom- 
panied by  a  diffuse  gray  to  a  black  discoloration,  pul- 
monary tuberculosis  is  sometimes  associated  with  a 
decided  brownish  discoloration  of  the  face,  while 


PHYSICIAN    AND    PATIENT.  275 

Addison's  disease  causes  a  smoky-gray  to  a  bronze 
discoloration. 

Remember  that  enlarged  veins  or  arteries  in  the 
skin  suggest  collateral  circulation,  due  to  some  deep- 
seated  obstruction.  The  veins  of  the  thoracic  wall 
are  enlarged  with  mediastinal  or  pulmonary  tumors 
that  compress  the  big  veins  within  the  chest.  En- 
larged veins  may  also  be  found  over  the  abdomen, 
due  to  portal  obstruction.  The  veins  about  the  navel 
become  enlarged,  forming  the  caput  madusae.  Ab- 
dominal tumors  will  cause  obstruction  by  pressure. 
Examine  the  skin  over  the  abdomen  for  nodular 
growths,  and,  when  found,  remember  they  are  ex- 
tremely significant  of  malignant  growths  of  the  ab- 
jiominal  cavity. 

Observe  the  fingers,  and  note  whether  they  are 
clubbed.  The  clubbing  is  due  to  a  swelling  of  the 
terminal  phalanges,  and  is  seen  only  in  congenital 
heart  disease,  chronic  pulmonary  disease,  most  fre- 
quently in  bronchiectasis  and  empyema,  but  some- 
times in  phthisis. 

In  fever  it  is  very  important  to  watch  the  daily 
course  of  the  temperature,  as  many  affections  have 
a  somewhat  characteristic  course,  as  typhoid,  ma- 
laria, lobar  pneumonia,  etc. 

Always  observe  the  respirations.  Note  their  fre- 
quency, the  type — whether  costal  or  abdominal — 
the  expansion  of  the  two  sides  of  the  chest,  and 
note  any  impairment  or  bulging  of  either  side  or 
the  intercostal  spaces. 


276  GENERAL    CONSIDERATIONS. 

In  observing  the  pulse,  note  the  frequency, 
volume,  tension,  and  regularity.  Palpate  the  wall 
of  the  vessel  to  determine  the  presence  of  arterio- 
sclerosis. A  good  method  to  determine  sclerosis  is 
to  grasp  the  patient's  wrist  with  the  left  hand  and 
elevate  the  forearm.  With  the  forefinger  of  the 
right  hand  make  compression  on  the  radial  artery 
strong  enough  to  destroy  the  perception  of  the  pulse 
with  the  middle  finger  just  below  the  point  of  com- 
pression. Then,  if  the  vessel  can  be  rolled  under 
the  middle  finger,  sclerosis  exists. 

Remember  that  the  pulse  rate  is  increased  by 
fever,  during  digestion,  and  by  coughing.  The  tem- 
perature and  pulse  curve  in  fever  usually  run  par- 
allel. The  pulse  increases  eight  beats  for  every 
degree  of  fever.  In  some  conditions  we  find  high 
temperature  with  slow  pulse,  as  in  febrile  brain 
disease  and  tubercular  meningitis. 

A  slow  pulse  rarely  occurs  as  an  individual  pecu- 
liarity, but  it  is  found  in  "fatty,"  infiltrated  heart 
and  sclerosis  of  the  coronary  arteries. 

A  capillary  pulse  is  most  frequently  observed  in 
aortic  insufficiency.  It  is  best  appreciated  by  ob- 
serving the  alternate  blushing  and  pallor  of  the 
finger  nail.  A  clean  glass  slide  pressed  lightly  upon 
the  extended  lower  lip  will  sometimes  bring  it  out 
when  it  can  not  be  observed  in  the  finger  nail.  An- 
other useful  method  is  to  rub  a  spot  on  the  forehead 
until  it  becomes  hyperemic  and  look  for  an  alterna- 
tion of  redness  and  pallor. 


PHYSICIAN   AND    PATIENT.  277 

A  liver  pulse  may  be  felt  as  a  pulsation  along  the 
lower  border.  It  is  found  most  often  in  valvular 
lesion  of  the  heart. 

Always  examine  the  excretions  and  secretions  of 
the  body.  For  methods  and  significance  of  findings 
consult  some  work  on  that  subject. 

Remember  that  palpation  is  the  most  valuable  of 
the  methods  of  examining  the  abdomen.  The  pa- 
tient should  lie  in  bed  and  the  abdomen  should  be 
bared.  The  hands  of  the  physician  should  be 
warmed,  and  palpation  should  be  done  by  gentle 
pressure.  Frequently  the  tips  of  the  fingers  used 
in  palpating  reveal  more  than  the  palms. 

There  are  two  ways  of  palpating  the  abdomen, 
Tind  the  one  to  use  depends  upon  the  part  to  be  pal- 
pated. Thus,  bimanual  palpation  may  be  from  side 
to  side,  the  wall  of  the  abdomen  being  deeply  folded 
between  the  hands.  Any  accessible  organ  or  tumor 
may  thus  be  studied.  Or  the  lateral  regions  of  the 
abdomen  are  best  palpated  by  placing  one  hand 
posteriorly  and  the  other  anteriorly.  In  this  man- 
ner the  liver  may  be  raised  against  the  anterior  wall 
and  the  lower  border  examined,  or  a  palpable  kid- 
ney brought  within  the  grasp  of  the  palpating  hands, 
or  the  splenic  enlargement  studied,  or  carcinoma  of 
the  sigmoid  flexure  palpated.  By  this  method  deep 
fluctuation  may  be  elicited  in  renal  or  appendiceal 
abscess  or  a  hydronephrosis  studied.  Where  tender- 
ness exists,  it  is  better  to  watch  the  expression  of 
the  patient's  face  than  to  depend  upon  any  state- 
ment he  may  make. 


278  GENERAL    CONSIDERATIONS. 

In  palpating  an  abdomen,  always  distinguish  be- 
tween superficial  and  deep  tenderness.  The  super- 
ficial is  due  to  hyperesthesia  of  the  skin,  and  a  light 
touch  causes  more  pain  than  firm  pressure.  This 
condition  is  frequent  in  hysterical  women. 

Pain  caused  by  deep  pressure  signifies  an  inflamed 
or  congested  organ. 

Excessive  abdominal  fat  will  prevent  obtaining 
accurate  information  by  palpation. 

When  the  abdominal  muscles  become  tense,  due 
to  apprehension,  excitement,  or  other  nervous 
causes,  elevate  the  head  upon  pillows  and  have  the 
limbs  flexed  at  hips  and  knees. 

Use  should  be  made  of  respiration  in  palpating 
abdominal  organs.  Thus,  continuous  deep  breath- 
ing will  be  very  helpful  in  determining  either  the 
borders  of  an  organ  or  to  what  organ  a  tumor  prob- 
ably belongs,  or,  again,  rapid  breathing  will  assist. 

There  must  be  a  systematic  examination  of  the  ab- 
domen. The  following  outline  will  be  of  assistance 
and  is  given  merely  as  a  guide: 

1.  Condition  of  the  abdominal  wall. 

2.  Fluctuation,  general  and  local. 

3.  Pulsation,  thrill,  and  fremitus. 

4.  Eespiratory,  postural,  and  manipulative  move- 
ments of  organs  or  tumors. 

5.  Peristaltic  and  fetal  movements. 

6.  Outline  and  relation  of  palpable  tumors. 

7.  Density  and  elasticity  of  the  tumors. 

8.  Nature  of  the  surface  of  the  tumors. 


INDEX. 


Abscess  of  the  liver   (see  Diseases 

of  the  liver) 
Acute  bronchitis    (see  Diseases  of 
the  lungs  and  pleurse) 
endocarditis   (see  Diseases  of  the 

vascular  system) 
enteritis  (see  Diseases  of  the  in- 
testines) 
nephritis    (see   Diseases    of   the 

kidneys  and  bladder) 
pancreatitis   (see  Diseases  of  the 

pancreas  and  peritoneum) 
peritonitis    (see  Diseases  of  the 

pancreas  and  peritoneum) 
pleurisy     (see    Diseases    of    the 

lungs  and  pleurse) 
yellow  atrophy    (see  Diseases  of 
the  liver) 
Addison's  disease   (see  Diseases  of 

the  ductless  glands) 
Alcoholic    cirrhosis     (see    Diseases 
of  the  liver — Portal  cirrhosis) 
Amebic  dysentery    (see   Infectious 

diseases) 
Anemia,   pernicious    (see   Diseases 

of  the  blood) 
Angina   pectoris    (see   Diseases   of 

the  vahnilar  system) 
Appendicitis    (see  Diseases  of  the 

intestines) 
Arteriosclerosis     (see    Diseases    of 
the  valvular  system) 
test  for,  276 
Arthritis  deformans   (see  Constitu- 
tional diseases) 
Asthma,  bronchial   (see  Diseases  of 

the  lungs  and  pleurse) 
Atrophy,    acute    yellow    (see    Dis- 
eases of  the  liver ) 

B 

Bacillary  dysentery  (see  Infectioiis 

diseases ) 
Biliary  cirrhosis    (see  Diseases  of 

the  liver ) 


Bladder,  diseases  of  the  (see  Dis- 
eases of  the  kidneys  and 
bladder) 

Blood,  diseases  of  the  (see  Dis- 
eases of  the  blood) 

Bowel,  obstruction  of  the  (see  Dis- 
eases of  the  intestines) 

Bronchial  asthma  (see  Diseases  of 
the  lungs  and  pleurae) 

Bronchiectasis  (see  Diseases  of  the 
lungs  and  pleurse) 

Bronchitis,  acute    (see  Diseases  of 
the  lungs  and  pleurse ) 
chronic     (see    Diseases    of    the 
lungs  and  pleurae) 

Broncho-pneumonia  (see  Diseases 
of  the  lungs  and  pleurse) 

C 

Cancer,  gastric  (see  Diseases  of 
the  stomach) 

of  the  liver   (see  Diseases  of  the 
liver) 
Carcinoma    of    the    pancreas     (see 
Diseases  of  the  pancreas  and 
peritoneum) 
Cholangeitis,  suppurative  (see  Dis- 
eases of  the  gall  bladder) 
Chlorosis     (see    Diseases     of     the 

blood) 
Chronic  bronchitis  (see  Diseases  of 
the  lungs  and  pleurae) 

constipation  ( see  Diseases  of  the 
intestines) 

enteritis  (see  Diseases  of  the  in- 
testines) 

interstitial  nephritis  (see  Dis- 
eases of  the  kidneys  and 
bladder) 

interstitial  pneumonia  (see  Dis- 
eases of  the  lungs  and 
pleurse ) 

pancreatitis  (see  Diseases  of  the 
pancreas  and  peritoneum) 

parenchymatous  nephritis  (see 
Diseases  of  the  kidneys  and 
bladder ) 


279 


280 


INDEX. 


Cirrhosis,    alcoholic    (see   Diseases 
of    the    liver  —  Portal    cir- 
rhosis ) 
biliary      (see    Diseases     of     the 

liver ) 
Lsennec's     (see    Diseases    of    the 

liver — Portal   cirrhosis ) 
portal  (see  Diseases  of  the  liver) 
Colitis,    mucous    (see    Diseases    of 

the  intestines) 
Considerations,   general    (see  Gen- 
eral considerations) 
Constipation,  chronic  ( see  Diseases 

of  the  intestines) 
Constitutional  diseases,  260 
Arthritis  deformans,  260 
Heberden's  nodes,  261 
joint  changes,  260 
joint  destruction,  260 
joint  distortion,  262 
joint  restoration,  260 
joint  swelling,  261 
muscular  atrophy,  261 
onsets  vary,  260 
pain  spontaneous,  260 
pigmentation  of  skin,  261 
pulse,  261 

simulating  rheumatism,  260 
symptoms,  261 
Treatment,  262 
baths,  262 
diet,  262 

Fowler's  solution,  262 
massage,  262 
medicinal,  262 
rest,  262 

superheated  air,  262 
Diabetes  mellitus,  267 
coma,  268 
diabetic  tabes,  268 
examination  of  urine,  268 
gangrene,  268 
signs,  267 
symptoms,  267 
urinalysis,  268 
Treatment,  269 
clothing,  269 
coma,    270 
diet,  269 
exercise,  269 
fatality,  271 
massage,  269 


Constitutional  diseases — cont'd 
medication,  269 
prescriptions,  270 
skin,  269 
venesection,  270 
Gout,  263 

aortic  second  sound,  265 
arteriosclerosis  coexistent,  263 
arthritis,  263 
causes,  263 
family  history,  264 
gastrointestinal  catarrh,  264 
gouty  diathesis,  264 
leucocytosis,  264 
liquor  as  cause,  263 
lithemia,  264 
nutritional  disorder,  263 
occupation,  264 
premonitory  signs,  263 
recurrent  attacks,  263 
symptoms,  263,  264 
uric  acid,  263 
Treatment,  265 
acute  attack,  265 
diet,  266 
exercise,  266 
lithemic  patients,  267 
medication,  265 
prescriptions,  265,  266 
relief  of  pain,  265 
symptoms     of    poisoning, 

266 
uric  acid,  266 
Cystitis    (see  Diseases  of  the  kid- 
neys and  bladder) 
Cysts,  pancreatic    (see  Diseases  of 
the    pancreas     and    perito- 
neum) 


D 


Diabetes    mellitus     (see    Constitu- 
tional diseases) 

Diphtheria      (see     Infectious     dis- 
eases) 

Disease,  Addison's  (see  Diseases  of 
the  ductless  glands) 
Hodgkin's    (see   Diseases  of  the 

blood — Pseudoleukemia ) 
of  the  heart,  valvular   (see  Dis- 
eases  of   the   vascular   sys- 
tem) 


INDEX. 


281 


Diseases,  constitutional    (see  Con- 
stitutional diseases) 
infectious     (see    Infectious    dis- 
eases) 
Diseases  of  the  blood,  102 
Chlorosis,  102 
anemia  test,  102 
capricious  appetite,  102 
causes,  102 

hyperacidity  of  stomach,  103 
sjTnptoms,  102 
Treatment,  103 

atony  of  bowels,  104 
Eland's  pills,  104 
constipation,  104 
diet,  103 
electricity,  103 
exercise,  103 
gastralgia,  104 
massage,  103 
prescriptions,   104-106 
rest,  103 
Leukemia,  108 

enlargement  of  lymph  glands, 

109 
enlargement  of  spleen,  109 
enlargement  of  tonsils,  109 
hematemesis,   109 
lymphemia,  109 
necrosis,   109 
onset  insidious,  108 
symptoms,  108 
Treatment,  110 
diet,  1 10 

Fowler's  solution,   110 
fresh  air,  110 
rest,- 110 
x-ray,  110 
Pernicious  anemia,  106 

circulatory  disturbances,  107 
examination  of  blood,   107 
jaundice,  106 
nervous  symptoms,  106 
onset  insidious,  106 
peripheral  neuritis,  106 
pulse,  107 

spastic  paraplegia,  106 
symptoms,  106 
tabes  dorsalis,  106 
Treatment,  107 
diet,  107 
Fowler's  solution,  107 


Diseases  of  the  blood — cont'd 
fresh  air,  107 
hypodermoclysis,  108 
rest,  107 
Pseudoleukemia   (Hodgkin's  dis- 
ease), 110 
blood  count.  111 
chronic  tonsillitis,  110 
enlargement    of    the    axillary 

glands.   111 
enlargement    of    the    inguinal 

glands.  111 
examination  of  blood,  110 
examination  of  teeth,  110 
histologic  changes.  111 
periadenitis.   111 
pressure  symptoms.   111 
pruritus,    111 
recurring  boils.  111 
temperature  curve.  111 
tubercular  adenitis,  111 
tuberculous    glands    of    neck, 
111 
Treatment,  112 

Fowler's  solution,  112 
prescriptions,  112 
surgery,  112 
x-ray,  112 
Purpura,  113 

erythematous  eruptions,   113 
hemorrhage,  113 
macular  eruptions,  113 
papular  eruptions,  113 
purpura  rheumatica,   113 
symptoms,  113 
tonsillitis,  113 
urti carious  eruptions,   113 
Treatment,  114 
cathartics,  114 
diet,  114 

prescriptions,  114,  115 
Diseases  of  the  ductless  glands,  IIG 
Addison's  disease,  116 
asthenia,  117 
gastric  disturbances,  116 
muscular  prostration,  117 
onset  insidious,  116 
pigmentation,  116 
symptoms,  116 
tubercular      degeneration      of 

glands,  117 
tuberculin  test,  117 


282 


IN'DEX. 


Diseases  of  the   ductless   glands — 
cont'd 

Treatment,  117 

diarrhea,    117 

diet  117 

organotheraphy,    118 

prescriptions,  117,  118 

rest,  117 
Exophthalmic  goiter,  118 
common  in  women,  118 
edema  of  feet,  120 
emaciation,  120 
exophthalmos,  118,  119 
goiter,  118 
Grafe's  sign,  119 
Joffroy's   sign,  119 
mental  condition,  120 
Mobius'  sign,  119 
pulsation,   118,  119 
Stellwag's  sign,  119 
sweating,  120 
symptoms.  118 
tachycardia,  118,  119 
test  for  tremor,  120 
tremor,  118,  120 
tumor,  118 

Treatment,  120 

Beebe  and  Eogers'  serum. 
122 

diet,  121 

electrotherapy,  121 

Foreheimer's  method,   122 

fresh  air,  121 

hydrotherapy,  121 

medication,  121 

Merck's  serum,   122 

Ortner's  method,  122 

prescriptions,  121 

rest,  120 

rodagen,  122 

surgery,   122 
Myxedema,  123 

atrophy  of  thyroid,  123 
causes,  123 
cretinism,  123 
facial  expression,  124 
mental  dullness,  124 
onset  insidious,  124 
symptoms,  123,  124 
Treatment,  125 

extract  of  thyroid  gland, 
125 


Diseases   of  the   ductless  glands — 
cont'd 

Foreheimer's  dosage,   125 
infantile   form   of   cretin- 
ism, 125 
prescriptions,   125 
symptoms  in  children,  126 
Diseases  of  the  gallbladder,  57 
Gallstones,  57 

area  of  tenderness,  58 
catarrhal  inflammation,  57 
causes,  57 
friction  sound,  58 
gallstone  colic,  57 
gastralgia,   58 
hematemesis,  58 
peptic  ulcer,  58 
pulse,  57 
sweating,   57 
symptoms,   57 
yomiting,  57 
Treatment.  58 
acute  attack,   58 
chloroform  inhalations,  58 
dissoh'ing  stones,  59 
gallstone  colic,  58 
hypodermatic,  58 
inter^-al,  58,  59 
prescriptions,    59 
surgery,  60 
Suppuratiye   cholangeitis,  60 
causes,  60 
gallbladder,  61 
icterus,   60 
infection,  60 
leucoeytosis,  61 
malaria,  61 
pain  yariable,  60 
pancreatic  ducts,  60 
progressiye     hepatic     enlarge- 
ment, 60 
symptoms  of  active  infection, 
'  60 
Treatment,  61 
surgery,  61 
Diseases  of  the  intestines,  26 
Acute  enteritis,  26 
albumin  casts,  26 
causes,  26 
colic,  26 

diarrhea    dominant    symptom, 
26 


INDEX. 


283 


Diseases  of  the  intestines — cont'd 

edema,  26 

fever,  27 

pain  varies,  26 
Treatment,  27 
cathartics,   27 
colon  irrigation,  28 
continual  seepage,  29 
diet,  28 

hypodermatic,  27 
medicinal,  28 
prescriptions,  28,  29 
sudorifics,  27 
teehnie  of  continual  seep- 
age, 29 
Appendicitis,  37 

dyspepsia  in  masked,  38 

diarrhea  in  masked,  38 

examination  in  masked,  39 

fever,  37 

gangrene,  37 

masked,  38 

masking  of  symptoms,  38 

pain  in  masked,  39 

palpation  in  masked,  39 

perforation,  37 

symptoms,   37 

tenderness  about  rectum,  38 

tenderness       at       McBurney's 
point,  38 

typhoid  bacilli,  38 
Treatment,  39 

continuous  seepage,  39 
Ochsner's  method,  39 
perforation  probable,  39 
peritonitis  probable,  39 
surgery,  39 

washing  out  stomach,  39 
Chronic  constipation,  34 

causes,  34 

colic,  35 

colonic  ulceration,  34 

diarrhea,  34 

dysmenorrhea,  34 

occlusion  of  bowel,  34 

perforation,  34 

piles,  34 

sacral  neuralgia,  34 

symptoms^  35 
Treatment,  35 
diet,  35 
drugs,  35 


Diseases  of  the  intestines — cont'd 

enemata,  35 

massage,  35 

physical  exercise,  35 

prescriptions,  35,  36 

stools,  35 
Chronic  enteritis,  30 
colicky  pains,  30 
colitis,  30 
constipation,  30 
diarrhea,  30 

examination  of  stools,  30 
indications  of  enteritis,  30 
sago-pearls,  30 
Treatment,  30 

astringents,  31 

colon  irrigation,  31 

diet,   30 

examination  of  stools,  30 

laxatives,  31 

medicinal,    31 

prescriptions,    31,   32 
Mucous  colitis,  40 
colicky  pain,  40 
neurosis,  40 
symptoms^  40 
tenderness  over  colon,  40 
tenesmus,  40 
urticaria,  40 
Treatment,  40 

diet,  40 

irrigation  of  colon,  41 

physical  exercise,  40 

relief  of  pain,  41 

Weir-Mitchell  feeding,  41 
Obstruction  of  the  bowel,  32 
complete  obstruction,  33 
distention  of  abdomen,  32 
fecal  retention,   32 
iliocecal  junction^  33 
intussusception,  33 
symptoms  vary,  32 
tenesmus,  33 
termination,  33 
tumor,  33 

Treatment,  34 

cathartics,  34 

enemata,  34 

purgatives,  34 

surgery,  34 
Visceroptosis,  41 
symptoms,  42 


284 


INDEX. 


Diseases  of  the  intestines — cont'd 
technic  to  determine  displace- 
ment, 41 
Treatment,  43 
caution,  44 
diet,  43_ 

mechanical  support,  43 
medicinal,  44 
Weir-Mitchell  feeding,  43 
Diseases  of  the  kidneys  and  blad- 
der, 71 
Acute  nephritis,  73 
albumin,  74 
anasarca,  73 
anemia,  74 
Bright's  disease,  73 
causes,  73 
dropsy,  73 

examination  of  urine,  74 
pleural   effusions,   74 
scarlatina,  73 
syphilitic  nephritis,   74 
typhoid,  73 
uremia,  73 

Treatment,  74 
diaphoretics,  77 
diet,  75 
diuretics,  76 
etiological  factor,  74 
purging,  77 
malaria,  74 
Petit's  triangle,  75 
prescriptions^  76-78 
salicylic  acid,  75 
symptomatic,  75 
syphilis,  74 
venesection,  75 
Chronic  interstitial  nephritis,  81 
arteriosclerosis,  81 
cardiovascular  findings,  81 
chronic  bronchitis,  82 
edema,  82 

enlarged  prostate,  81 
hypertrophy  of  heart,  82 
impaired  vision,  82 
pulse,  82 

retinal  findings,  81 
urinary  findings,  81 
urine,  81 

Treatment,  82 

arterial  tension,  83 
bowels,  83 


Diseases  of  the  kidneys  and  blad- 
der— cont'd 

clothing,  83 
diet,  82 
diuretics,   82 
skin,   83 

syphilitic  nephritis,  83 
worry,  83 
Chronic  parenchymatous  nephri- 
tis, 78 
albuminuria  retinitis,  79 
anemia,  78 
asthma,  79 
edema,  78 
epilepsy,    78 
uremic  dyspnea,  78 
urine,  78 
vomiting,  79 
Treatment,  79 

Basham's  mixture,  81 
baths,  80 
bowels,  81 
clothing,   80 
diet,  7p 
diuretics,  81 
rest,  79 
salt,  80 
water,  80 
Cystitis,  98 
bacteria,  98 

examination  of  bladder,  98 
hypertrophied  bladder,  98 
interrupted  micturition,  98 
tubercle  bacilli,  98 
tubercular  cystitis,  98 
urinalysis,  98 
Treatment,  99 
cathartics,  99 
causal  therapy.  100 
chronic  form^  100 
crushing  stone,  99 
diet,  99 

prescriptions,  99-101 
relief  of  pain,  99 
removal  of  stone,  99 
urinary  antiseptics,   99 
Hydronephrosis,  91 
aspiration,  91 
congenital.  91 
mistaken  for  ascites,  91 
mistaken  for  ovarian  cysts,  91 
tumor,  91 


INDEX. 


285 


Diseases  of  the  kidneys  and  blad- 
der— cont'd 

Treatment,  92 
aspiration,  92 
bandage,  92 
drainage,  92 
incision,  92 
nephrectomy,  92 
Movable  kidney,  71 
floating  kidney,  71 
hydronephrosis,  72 
hysteria,  71 
jaundice,  72 
nephroptosis,  72 
palpable  kidney,  71 
palpation,  71 
symptoms,  72 
Treatment,  72 
bandage,  72 
forced  feeding,  72 
rest,  72 
surgery,  73 
tonic,  73 
Nephrolithiasis,  92 
cause  of  stones,  92 
focus  of  pain,  93 
hematuria,  93 
gravel,  92 
renal  calculi,  93 
renal  colic,  92 
sand,  92 
stone,  92 
symptoms,  93 
vesical  calculi,  93 
x-ray,  93 

Treatment,  94 
baths,   94 

chloroform  inhalations,  94 
diet,  96  _ 
dyspepsia,  97 
examination  of  urine,  94 
hyperacidity,  97 
neurasthenia,  97 
prescriptions,  94-97 
renal  colic,  94 
surgery,  97 
Pyelitis,  89 
cystitis,  89 

painful  micturition,  89 
polyuria,  89 
pyuria,  89 
reaction  of  urine,  89 


Diseases  of  the  kidneys  and  blad- 
der— cont'd 
symptoms,  89 
tumor,  89 

Treatment,  89 
antiseptics,  90 
astringents,  91 
baths,   89 
congestion,  90 
diet,  89 

gastric  disturbances,  90 
leeches,  90 

prescriptions,   90,   91 
relief  of  pain,  90 
Uremia,  84 

albuminuric  retinitis,  85 
asthenia,  84 
brain  tumor,  85 
Bright's  disease,  84 
Cheyne-Stokes  breathing,  84 
coma,  84,  85 
headache,   84 
hemiplegia,  84 
impaired  vision,  84 
latent  form,  84 
meningitis,  85 
miliary  tuberculosis,  85 
muscular  cramps,  84 
odor  of  breath,  86 
pulse,  84 

uremic  dyspnea,  84 
urinalysis,  84 
vomiting,  84 
Widal  reaction,  85 
Treatment,  86 

acute  attack,  86.  88 
cardiac  tonics,  86 
cathartics,  86 
chronic  attack,  88 
convulsions,  87 
diaphoretics,  86 
diarrhea,  88 
diet,    88 
lavage,  88 
prescriptions,  86-88 
Renon's  water  diet,  88 
uremic  asthma,  88 
venesection,  86 
vomiting,  87 
Diseases  of  the  liver,  45 
Abscess  of  the  liver,  52 
cases  resemble  malaria,  53 


286 


INDEX. 


Diseases  of  the  liver — cont'd 
causes,  53 

dislocation  of  heart,  54 
enlarged  liver,  53 
puncturing  of  liver,  54 
uncertainty  of  diagnosis,  52 
Treatment,  54 

inefficacy  of  drugs,  54 

preventive,  54 

surgery,  54 
Acute  yellow  atrophy,  54 
biliary  cirrhosis,  54 
coma,  54 

pregnancy  a  factor,  54 
reduction  of  liver,  55 
symptoms,  54 
urinalysis,  55 
Treatment,  55 

cathartics,  55 

gastric  sedatives,  55 
Biliary  cirrhosis,  51 
cancer  of  liver,  52 
chronic  icterus,  51 
chronic  jaundice,  51 
enlarged  spleen,  51 
gallstones,  51 
Hanot's  cirrhosis,  51 
hemorrhage,  51 
heredity  as  factor,  51 
malignant  disease  of  liver,  51 
symptoms,   51 
Treatment,  52 

bowels,  52 

diet,  52 

quiet  life,  52 
Cancer  of  the  liver,  55 
ascites,  56 
age  when  occurs.  55 
enlarged  liver,  56 
enlarged  lymph  glands,  56 
emaciation,  56 
fatality,  56 
icterus,  56 
liver  dullness,  56 
nodular  form,  55 
primary,  55 
secondary,  55 
tumor  form,  55 
uncertainty  of  diagnosis,  55 
Treatment,  56 

palliative,  56 

surgery,  56 


Diseases  of  the  liver — cont'd 
Icterus  (jaundice),  45 
a  symptom,  45 
causes,  45 

examination  of  gallbladder,  45 
examination  of   liver,   45 
examination  of  urine,  45 
hemorrhage^  45 
pulse,  45 
respirations,  45 
stools,  45 
test  for,  45 
Treatment,  46 
diet,  46 
enemata,  46 
prescriptions,  46,  47 
purgatives,  46 
Portal    cirrhosis    (Lannec's    cir- 
rhosis,  alcoholic   cirrhosis), 
47 
albumin,  48 
alcoholic  history,  47 
examination  of  pelvis  in  wom- 
an, 48 
hemorrhage.  48 
nodules  of  liver,  48 
nutmeg  liver,  48 
ovarian  cyst,  48 
urea  excretion,  48 
Treatment,  48 
alcohol,  48 
ascites,  49,  50 
bowels,  49 
diarrhea,  49 
diet,  48 

hematemesis,  49 
prescriptions,  49,  50 
surgery,  50 
Diseases  of  the  lungs  and  pleurae, 
163 
Acute  bronchitis,  163 
atelectasis,  164 
bronchial  fremitus,  164 
bronchi-pneumonia,  164 
capillary  bronchitis,  164 
Charcot's  crystals  in  sputum, 

164 
cough,  163 
dyspnea,  164 

examination  of  chest,   164 
fever,  163 
fremitus,  104 


INDEX. 


287 


Diseases  of  the  lungs  and  pleurae — 
cont'd 

percussion  sound,  164 
prolonged  expiration,  163 
spirals  in  sputum,   164 
substernal  soreness,  163 
symptom  in  malaria,  163 
symptom  in  typhoid,  163 
vesicular  murmur,  163 
Treatment,  164 
baths,  164 
bowels,  165 
diet,  167 
foot  bath,  164 
mustard  plaster,  164 
prescriptions,  165-167 
Acute  pleurisy,  211 
auscultation,   211 
differentiating     pleurisy     and 

pneumonia^  213 
displacement  of  organs,  213 
dyspnea,  211 

effusion  into  pleural  sac,  212 
fever,  211 
focus  of  pain,  211 
Grocco's  triangle  of   dullness, 

212 
posture  of  patient,  212 
Skoda's  resonance,  212 
symptoms,  211 
tumor  of  mediastinum,  213 
withdrawal  of  fluid,  213 
Treatment,  213 
aspiration,  214 
diet,  214 

Potain's  aspirator,  214 
prescriptions,  215 
rest,  213 

technic  of  aspiration,  214 
Bronchial  asthma,  175 

appearance  of  patient,  175 
Charcot's  crystals,  176 
Curschmann  spirals,  176 
dyspnea  in  bronchial  asthma, 

176 
dyspnea  in  cardiac  asthma,  176 
eosinophils  of  blood,  176 
expiration,  175 
inspiration,  175 
premonitory  symptoms,  175 
spasm  of  glottis,  176 
sputum,  175 


Diseases  of  the  lungs  and  pleurae — 
cont'd 

symptoms,  175 
symptoms  of  dyspnea,  176 
symptoms  of  emphysema,  176 
Treatment,  176 
attack,  176,  177 
bowels,  179 
change  of  climate,  179 
chloroform       inhalations, 

177 
chronic  hronchitis,  179 
diet,  179 
emphysema,  179 
interval,  176,  178 
nitrite  of  amyl,  177 
prescriptions,  178,  179 
Bronchiectasis,  172 
cerebral  abscess,  173 
cough,  173 
grippe,  172 
sputum,   172 
symptoms,  173 
tuberculosis  of  lungs,   173 
Treatment,  173 

internal  antiseptics,  173 
prescriptions,  173,  174 
surgery,  174 
vapor  bath,  174 
Broncho  -  pneumonia    (lobular 
pneumonia),   190 
age  when  occurs,  190 
Bright's  disease,  190 
cyanosis,  190 
dyspnea,  190 
miliary  tuberculosis,  191 
percussion,   191 
symptoms,  190 
terminal  event,  190 
tubercle  bacilli,  190 
Treatment,  191 
bowels,  191 
diet,  193 
fever,  191 
pulse,   193 

prescriptions,  192.  193 
proper  care  of  child,  191 
tonics,  193 
venesection,  193 
Chronic  bronchitis,  167 
bronchorrhea,  168 
coexisting  emphysema,  168 


288 


INDEX. 


Diseases  of  the  lungs  and  pleurae — 
cont'd 

examination  of  heart,  168 
examination  of  urine,  168 
lung  tissue  in  sputum,   168 
occupation  a  factor,   167 
secondary  to  other  conditions, 

167 
shortness  of  breathy  168 
symptoms,  168 
tubercle  bacilli,  168 
uric  acidemia,   168 
winter's  cough,   168 
Treatment,  169 

bowels,  169 

change  of  climate,  169 

clothing,  169 

diet,  169 

dry  catarrh,  169 

moist  catarrh,  169 

nephritis,  172 

prescriptions,    169-172 
Chronic    interstitial   pneumonia, 
194 
apex  beat  of  heart,  194 
atrophy  of  lung,   194 
auscultation,  194 
cardiac  failure,  195 
chronic  cough,  195 
dyspnea,  195 
hemorrhage,  195 
history,   194 
sputum,  195 
tuberculosis,  195 
Treatment,  195 

breathing   exercise,    195 

change  of  climate,  195 

clothing,  195 

diet,  195 

severe  coughj  195 

skin,    195 
Edema  of  the  lungs,  179 
acute  edema,  180 
cyanosis,  180 
due  to  engorgement,  180 
dyspnea,  180 

exudations  into  alveoli,  179 
fatality,  180 
inflammatory,  180 
onset  sudden,  180 
pulse,  180 
second  pulmonic  sound,  180 


Diseases  of  the  lungs  and  pleurae — 

cont'd 

sputum,  180 
Treatment,  180 

bleeding,   180 

cardiac  stimulants,  180 

dry  cupping,  181 

mustard  draft,  181 

purging,  181 
Emphysema,  196 
bronchitis,  196 
cough,    196 
cyanosis,  196 
dyspnea,  196 
expectoration,  196 
heredity,   196 

hypertrophy  of  right  heart,  196 
percussion,   196 
second  pulmonic  sound.  196 
symptoms,  196 
Treatment,  197 

asthmatic  attacks,  197 

bowels,   197 

chronic  bronchitis,  197 

diet,  197 

Fowler's  solution,   197 

protection  from  exposure, 
197 
Lobar  pneumonia,  181 

acute      tuberculo  -  pneumonic 

phthisis,   185 
aspirator  needle,   185 
auscultation,   183 
broncho-pneumonia,  184 
cardiac  dullness,  183 
cerebrospinal  meningitis,  184 
chill,  181 
cyanosis,  181 
dyspnea,   181 
fever,   181 

focus  of  pain,  181,  182 
heart  failure,  183 
hemorrhagic  infarct,  184 
Kernig's  sign,  184 
leucocytosis,  184 
onset  sudden,  184 
palpation,  182 
percussion,  182 
pleurisy,  184 
profound  toxemia^  183 
pulmonary  second  sound,  183 
pulse,  182,  184 


INDEX. 


289 


Diseases  of  the  lungs  and  pleurae — 
cont'd 

respiration,  182 
second  heart  sound,  183 
Skoda's  resonance,  183 
sputum,  181,  184 
symptoms,  182 
urine,  183 

Treatment,  185 

baths,   186 

cold  sweating,  188 

conservation  of  heart,  185 

convalescence^  189 

cough,  187 

crisis,  189 

diet,  185 

expectorants,  187 

fresh  air,  185 

heart  failure,  187 

hypodermoclysis,  189 
-    isolation,  185 

prescriptions,  187-189 

relief  of  pain,  186 

rest,  185 

skin,    186 

sleeplessness,  187 

strapping  of  chest,  186 

tympanites^  186 

venesection,  187 
Pulmonary  gangrene,  197 
fever,  198 
sequence    of    lung    conditions, 

197 
sputum,   198 
symptoms,  198 
typhoid,  197 
Treatment,  198 

carbolic  inhalations,  198 

diet,  198 

position  of  patient,  198 

prescriptions,   199 

stimulants,  198 

surgery,   199 
Pulmonary  tuberculosis^  199 
auscultation,  199,  202 
breathing,  201 
catarrh,  199 
cough,  200 
family  history,  202 
hectic  fever,  200 
hemorrhage,  201 
Koch's  tuberculin,  201 


Diseases  of  the  lungs  and  pleurae — 
cont'd 

loss  of  weight,  199 

night  sweats,  200 

pain  in  chest,  201 

percussion,   199 

pulse,  201 

rigid  muscleSj  201 

sputum,  200 

symptoms,  199 

temperature,  199 

test   for   tubercular   infection, 

201 
tubercle  bacilli,  200 
Treatment,  202 

anorexia,  207 

care  of  mouth,  203 

cough,  208 

diet,  202 

exercise,  203 

fever,  207 

hemorrhage,  208 

inhalations,   204 

medicinal  therapy,  203 

mercurial  treatment,  210 

night  sweats,  208 

prescriptions,  204-209 

skin,  208 

sleeping  arrangements,  203 

sputum,  211 

ventilation,  203 
Diseases  of  the  pancreas  and  peri- 
toneum, 62 
Acute  pancreatitis,  63 
intestinal  obstruction,  83 
onset  sudden,  63 
symptoms,  63 
Treatment^  64 

collapse,  64 

pain,  64 

rectal  feeding,  64 

surgery,  64 
Acute  peritonitis,  68 
arteriosclerosis,   68 
Blight's  disease,  68 
clinical  picture,  68 
enterocolitis,  69 
facies,  68 
focus  of  pain,  68 
gout,  68 

Hippocrates'  facies,  69 
hysteria,  69 


290 


INDEX. 


Diseases  of  the  pancreas  and  peri- 
toneum— cont'd 

inflammation    of    peritoneum, 

68 
inflammation  of  viscera,  68 
intestinal  obstruction,  69 
mental  condition,  68 
pulse,  68 
respiration,  69 
shock,  68 
symptoms,  68 
tuberculosis,  69 
vomiting,  69 
Treatment,  70 

diet,  70 

Fowler's  position,  70 

saline  treatment,  70 

surgery,  70 
Carcinoma  of  the  pancreas^  66 
anorexia,  67 
ascites,  67 
bowels,  67 

distention  of  gallbladder,  66 
edema,  67 

enlargement  of  liver,  67 
immobile  tumor,  67 
interstitial   pancreatitis,  67 
jaundice,  67 
retention  cysts,  66 
Treatment,  67 

draining,  67 

extirpation  of  gland,  67 

palliative,  67 

rectal  feeding^  67 
Chronic  pancreatitis,  64 
anorexia,  64 
examination  of  feces,  64 
focus  of  pain,  64 
gallstones,   64 
glycosuria,  64 
indican,  65 

islands  of  Langerhans,  64 
jaundice,  64 
onset  gradual,  64 
palpation,  64 
Treatment,  65 

anastomosis,  65 

icterus,  65 

surgery,  65 
Hemorrhage,  62 
fatality,  62 
medico-legal  view,  62 


Diseases  of  the  pancreas  and  peri- 
toneum— cont'd 

mistaken    for    intestinal    ob- 
struction, 62 
onset  sudden,  62 
pulse,  62 
temperature,  62 
vomiting,  62 
Treatment,   62 

heart  depression,  63 
laparotomy,  63 
loss  of  blood,  62 
pain,  62 
Pancreatic  cysts,  65 
causes,  65 
constipation,  65 
examination  in  Trendelenburg 

position,  66 
glycosuria,  66 
jaundice,  65 
location,  65 
palpation,  65 
shape,  65 
tumor,  65 

tumor  of  transverse  colon,  66 
vomiting,  65 
Treatment,  66 
draining,  66 
surgery,  66 
Diseases  of  the  stomach,  9 
Gastric  cancer,  15 
anasarca,  15 
Boas-Oppler  bacillus,   16 
duration,   16 
edema,  15 
gastric  tumor,  15 
hepatic  tumor,   15 
hydrochloric  acid,  15 
increasing,  15 
inspection,  16 
lactic  acid,  16 
nodular  swellings,  15 
pain  of  carcinoma,  16 
palpation,   16 
symptoms,  15 

symptoms   of  pancreatic    can- 
cer, 16 
tumor,  15 
vomiting,  15 
Treatment,  17 
medicinal,  17 
prescriptions,  17,  18 


INDEX. 


291 


Diseases  of  the  stomach — cont'd 

relief  of  pain,  17 

surgery,  17 

washing  out  stomach,  17 
Gastric  ulcer,  9 
anemia,  10 
appetite,  11 
area  of  tenderness,  10 
cause  of  pain,  9 
dilatation,  10 
enlargement  of  liver,  11 
evidence,  10 

examination  of  stools,  11 
focus  of  pain,  9,  10 
frequency  in  women,  10 
hemorrhage,  10 
hydrochloric  acid,  9 
pain  after  healing,  10 
pain  of  gastralgia,  10 
perforation,  10 
relief  from  pain,  9 
stomach  tube,  11 
surgery  in  perforation,  11 
symptoms,  9 

symptoms  of  perforation,  11 
vomiting,  9 
Treatment,  11 

fasting,  11 

medicinal,  12 

prescriptions,  13-15 

rectal  feeding,  12 

rest  of  stomach,  11 
Gastritis,  18 

alcohol  as  factor,  19 
cardiac  palpitation,  19 
dyspnea,  19 
gastric  catarrh,  19 
history  of  case,   18 
locomotor  ataxia  simulates,  18 
majority  of  cases  afebrile,  18 
mistaken  for  gallstones,  18 
mistaken    for    infectious    dis- 
ease, 19 
mistaken  for  meningitis,  18 
portal  stasis,   19 
test  for  knee  jerk.  18 
test  for  reaction  of  pupil,  18 
Treatment,  19 

prescriptions,  19-22 

stomach  tube,  19 

vomiting,  19 

washing  of  stomach,  19 


Diseases  of  the  stomach — cont'd 
Hematemesis,  24 

anemia,  24 

blood  from  lungs,  25 

blood  from  stomach,  25 

edema,  25 

fatal  synocope,  24 

leukemia,  25 

rupture  of  varix,  25 
Treatment,  25 

absolute  quiet,  25 
hypodermatic,  25 
hypodermoclysis,  25 
medicinal,  25 
rectal  feeding,  25 
surgery,  25 
Hyperchlorhydria,  22 

cancer  excluded,  22 

children  affected,  23 

chlorosis,  22 

eructation,  22 

examination  of  stomach,  22 

gastritis  excluded,  22 

heartburn,  22 

hydrochloric  acid,  22 

hysteria,  22 

neurasthenia,  22 

pain  variable,  22 

relief  of  pain,  22 

salivation,  22 

symptoms  in  children,  23 

vomiting  of  sour  liquid,  22 
Treatment,  23 
diet,  23 
medicinal,  23 
prescriptions,  23,  24 
washing  out  stomach,  23 
Diseases    of   the   vascular    system, 
127 
Acute  endocarditis,  132 

auscultation,  132 

causes,  132 

precordial  pain,  132 

pulmonic  sound,  132 

simple  endocarditis,  132 

symptoms,  132 
Malignant  endocarditis,  132 

chills,  133 

emboli,    133 

fever,  133 

history,  132 

sweat,  133 


292 


INDEX 


Diseases  of  the  vascular  system — 
cont'd 

symptoms,  133 
Treatment,  133 
diet,  133 
enemata,  134 
rest,  133 

prescriptions,   134,   135 
Angina  pectoris,  154 
arteriosclerosis,   155 
common  in  men,  154 
factors,  154,  155 
neurotic  form,   155 
onset  sudden,  155 
symptoms,  155 
syphilitic  aortitis,  154 
Treatment,  156 
attack,  156 
bowels,  157 
chloroform       inhalations, 

156 
diet,  157_ 
elimination,  157 
hypodermatic     injections, 

156 
interval  treatment,  156 
nitrite    of    amyl    inhala- 
tions,  156 
prescriptions,  157,  158 
Arteriosclerosis,  158 
attacks  transient,  159 
causes,  158 
coronary  arteries,  159 
intermittent  claudication,  160 
symptoms,  159 
Treatment,  160 
baths,  160 
bowels,  160 
cathartics,  161 
diet,  160 

early  diagnosis,  160 
Fowler's  solution,  161 
kidneys,  160 
prescriptions,  160,  161 
quiet  life,  160 
venesection,  162 
Palpitation,  152 
anemia,  152 
causes,  152 

common  in  women,  152 
pulse,  152 
neurosis,  152 


Diseases  of  the  vascular  system — 
cont'd 

urine,  152 

Treatment,   153 
anemia,  153 
baths,  153 
diet,  153 

gastric  disturbances,  154 
prescriptions,    153,    154 
sexual  excitement,  153 
Weir-Mitchell    treatment, 
153 
Pericarditis,  127 

acute  fibrinous  stage,  127 
auscultation,  127 
cardiac  dilatation,  130 
cardiac  dullness,  129 
cardiac  effusion,  130 
causes,  127 

constitutional  signs,   128 
dysphagia,  129 
dyspnea,  128 
effusion,  128 
first  rib  sign,  129 
friction  sound,  127 
idiopathic  varieties,  127 
palpation,  128 

paralysis  of  vocal  cords,  129 
percussion,  129 
physical  signs,  128 
pleural  effusion,  130 
pulse,  128 
Rotch's  sign,  129 
singultus,  129 
symptoms,  128 
triangle  sign,  129 
vomiting,  129 
Treatment,  130 
constipation,  131 
diet,  130 
medicinal,  130 
prescriptions,  131 
rest,  131 

technic  of  aspiration,  131 
Valvular  diseases  of  the  heart, 
135  _ 
aortic  incompetency,  135 
auscultation,  136 
Austin-Flint  murmur,  137 
causes,  135 

examination  of  arteries,  136 
focus  of  pain,  135 


INDEX. 


293 


Diseases  of  the  vascular  system — 
cont'd 

mental   disturbances,    136 

pulse,  136 

symptoms,   135 
aortic  stenosis,  137 

arterial  changes,  137 

causes,  137 

muscular  hypertrophy,  137 

pulmonary  emphysema,  137 

pulsus  tardus,  137 

symptoms,  137 

systolic  thrill,  137 
mitral  incompetency,   138 

apex  beat,  139 

cardiac  sleep  start,  139 

clubbing  of  fingers,  138 

percussion,  139 

physical  signs,  139 

pulmonic  congestion,   139 

pulse,   139 

symptoms,  138 
mitral  stenosis,  140 

common  in  women,  140 

dullness,    140 

hypertrophy,  140 

location  of  murmur,  140 

paralysis  of  vocal  cords,  140 
tricuspid  insufficiency,  141 

crural  vein  sound,  141 

expansile  pulsation  of  liver, 
141 

symptoms,    141 

systolic  murmur,  141 
tricuspid  stenosis,  141 

cardiac  dullness,  141 

presystolic  murmur,  141 

symptoms,  141 
Treatment.  142 

Addison's  pills,  149 
arteriosclerosis,   146 
baths,  142 
cardiac  failure,  147 
cardiac  stimulants,  144 
cathartics,  142,  149 
clothing,  142 
cough,  150 
diet,  142 
dropsy,   147 
insomnia,  149 
mechanical,  142 
medication,  142 


Diseases  of  the  vascular  system — 
cont'd 

Nauheim  treatment,  150 
Niemeyer's  pills,  149 
paracentesis,  149 
prescriptions,  143-150 
rest,  142 

Schott  movements,  150 
venesection,  147 
Ductless    glands,    diseases    of    the 
(see  Diseases  of  the  ductless 
glands ) 
Dysentery,  amebic    (see  Infectious 
diseases ) 
bacillary     (see    Infectious     dis- 
eases.) 

E 
Edema  of  the  lungs    (see  Diseases 

of  the  lungs  and  pleurae) 
Emphysema    (see   Diseases   of   the 

lungs  and  pleurse) 
Endocarditis,   acute    (see   Diseases 
of  the  vascular  system) 
malignant    (see   Diseases  of  the 
vascular  system) 
Enteric  fever    (see  Infectious  dis- 
eases— Typhoid ) 
Enteritis,    acute    (see  Diseases   of 
the  intestines) 
chronic   (see  Diseases  of  the  in- 
testines ) 
Exophthalmic  goiter   (see  Diseases 
of  the  ductless  glands) 

F 
Fever,  enteric   (see  Infectious  dis- 
eases— Typhoid ) 
rheumatic     (see    Infectious    dis- 
eases) 
scarlet  (see  Infectious  diseases) 

G 

Gallbladder,   diseases  of   the    (see 
Diseases  of  the  gallbladder) 

Gallstones     (see    Diseases    of    the 
gallbladder) 

Gangrene,  pulmonary  ( see  Diseases 
of  the  lungs  and  pleurse) 

Gastric  cancer  ( see  Diseases  of  the 
stomach) 
ulcer   (see  Diseases  of  the  stom- 
ach) 


294 


INDEX. 


Gastritis     (see    Diseases     of     the 

stomach ) 
General  considerations,  272 
Physician  and  patient,  272 
examination  of  abdomen,  278 
examination  of  excretions,  277 
examination  of  secretions,  277 
knowledge  of  anatomy,  272 
manipulation,  273 
observ^ations  of  patient,  272 
obtaining  history.  273 
palpation,  276,  277 
patient's  confidence,  272 
physical  characteristics,  274 
physical     examinations,     272, 

273 
physician's  bearing,  272 
posture  of  patient,  273,  274 
test  for  arteriosclerosis^  276 
Glands,    ductless,    diseases    of    the 
( see  Diseases  of  the  ductless 
glands ) 
Goiter,  exophthalmic  (see  Diseases 

of  the  ductless  glands) 
Gout  (see  Constitutional  diseases) 

H 

Heart,  vah^ilar  disease  of  the  (see 
Diseases  of  the  vascular  sys- 
tem) 

Hematemesis  (see  Diseases  of  the 
stomach) 

Hemorrhage  (see  Diseases  of  the 
pancreas  and  peritoneum) 

Hodgkin's  disease  (see  Diseases  of 
the  blood — Pseudoleukemia) 

Hydronephrosis  (see  Diseases  of 
the  kidneys  and  bladder) 

Hyperchlorhydria  (see  Diseases  of 
the  stomach) 


Icterus  (see  Diseases  of  the  liver) 
Infectious  diseases,  216 
Amebic  dysentery,  231 

acute,  231 

amebi  coli  in  stools,  231 

chronic,   231 

fever,  231 

indigestion,  231 

liver  abscess,  231 

onset  sudden,  231 


Infectious  diseases — cont'd 
palpation,  231 
perforation,  231 
peritonitis,  231 
symptoms,  232 
Treatment,  232 

diet,  232 

enemata,  232 

intestinal  antiseptics,  232 

local  treatment,  232 

rest,  232 
Bacillary  dysentery,  227 
bacilli  dvsenterise,  228 
bloody  flux,  228 
causes,  227 
epidemic,  227 

Flexner-Harris  bacilli,  228 
liver  abscess,  228 
onset  sudden,  227 
paralysis,  228 
paraplegia,  228 
Shiga  bacilli,  228 
symptoms,  227 
tenesmus,  228 
Treatment,  229 

diet,  229 

local  applications,  230 

medicinal,  229 

prescriptions,  229,  230 

rectal  irrigation,  230 

rest,  229 

serum  therapy,  230 
Diphtheria,  251 

bacterial        examination        of 

throat,  252 
carbonic  acid  poisoning,  251 
children  most  susceptible,  251 
diphtheria  carriers,  251 
diphtheritic  croup,  251 
direct  contagion,  251 
discharge  from  nose,  252 
enlargement  of  lymph  glands, 

252,  253 
indirect  contagion,  251 
Klebs-Loeffler  bacilli,  252 
membrane,  252,  253 
milk  a  cause,  251 
otitis  media,  251 
sore  throat,  252 
streptococci,  251 
symptoms,  251 
temperature,  252 


INDEX. 


295 


Infectious  diseases — cont'd 
tonsils,  252 
toxemia,  252 
Treatment,  253 
antitoxin,  254 
bowels,  254 
diet,  254 
hygienic,  253 
intubation,  254 
laryngeal  croup,  254 
local  treatment,  253 
rest,  254 

specific  treatment,  254 
stimulants,  254 
toxin,    254 
tracheotomy,  254 
ventilation,  253 
Malaria,  243 

bilious  fever,  245 
chronic  malaria,  247 
differentiating  typhoid  and  re- 
mittent fever,   246 
examination  of  blood,  245,  246 
fever  and  ague,  244 
herpes  labialis,  245 
intermittent  fever,  244 
mosquito  as  cause,  243 
number  of  types,  243 
pernicious  malaria,  246 
protection  from  mosquito,  243 
pyemia,  245 
remittent  fever,  245 
symptoms  of  chronic  malaria, 

247 
symptoms   of  intermittent  fe- 
ver, 244 
symptoms    of    pernicious    ma- 
laria, 246 
symptoms  of  remittent  fever, 

245 
tuberculosis  of  lungs,  245 
Treatment,  248 
Blaud's  pills,  250 
Fowler's  solution,  250 
masking  solution  of   qui- 

nin,  249 
mixed  treatment,  248 
prescriptions,  248-250 
protection  from  mosquito, 
248 
Measles,  233 
cough,  233 


Infectious  diseases — cont'd 
desquamation,   234 
differentiation  of  measles  and 

small-pox,  234 
eruption,  233 
fever,  233 
hemorrhage,  234 
Koplik's  spots,  234 
lobular  pneumonia,  234 
mastoid  abscess,  234 
onset  with  coryza,  233 
otitis  media,  234 
period  of  incubation,  233 
Treatment,  235 

cathartics,  235 

convalescence,  235 

cough,  235 

diet,  235 

eruption,  235 

fever,  235 

prescriptions,  235,  236 

rest,  235 
Eheumatic  fever    (inflammatory 
rheumatism),  255 
acute  infectious  disease,  255 
acute  osteomyelitis,  256 
anemia,  255 
arthritis,  256 
arthritis    deformans,   256 
causes,  255 

cerebral  rheumatism,  257 
differentiating      inflammatory 
rheumatism  and  tonsillitis, 
255 
examination  of  urine,  256 
fatality,  257 
fever,  256 

gonorrheal  arthritis,  256 
joint  changes,  256 
joints,  255 
Kernig's  sign,  256 
micro-organisms  as  cause,  255 
onset  sudden,  255 
pulse,  255 

rheumatism    simulating    men- 
ingitis, 256 
sweat,  255 

Treatment,  257 

clothing,  257 

convalescence,  25? 

diet,  257 

hyperpyrexia,  257 


296 


IKDEX. 


Infectious  diseases — cont'd 

prescriptions,  258,  259 
rest,  257 
Scarlet  fever  (scarlatina)^  236 

angina,  236 

differentiating   scarlatina   and 
measles,  237 

enlargement  of  lymph  glands, 
237 

examination  of  urine,  238 

eruption,  237 

inflammatory  rheumatism,  238 

milk  as  cause,  236 

onset  sudden,  237 

otitis  media,  238 

polyarthritis,  238 

symptoms,  237 

temperature,  237 

tongue  indications,  237 
Treatment,  239 

cardiac  failure^  241 
care  of  mouth,  239 
clothing,  239 
convalescence,  243 
delayed  eruption,  242 
delirium,  241 
examination  of  urine,  242 
fever,  240 
hydrotherapy,  240 
Lceffler's  solution,  240 
nephritis,  242 
prescriptions,    239-243 
prophylaxis,  239 
stimulants,  241 
twitching,  241 
ventilation,  239 
Typhoid  (enteric  fever) ,  216 

common  in  adults,  216 

enlargement  of  spleen,  218 

fatality,  220 

fever,  217 

intestinal  hemorrhage,  217 

mistaken  for  appendicitis,  217 

onset  sudden  in  children,  216 

onset  usually  gradual,  216 

pea-soup  stools,  218 

pulse,  218 

rose  spots,  217 

signs  of  perforation,  219 

signs  of  peritonitis,  219 

simulating  malaria,  218 

surgery,   219 


Infectious  diseases — cont'd 
sweating,  218 
symptoms,  216 
Widal  test,  218 
Treatment,  220 
baths,  222 
bed  sores,  225 
bowels,  223 
care  of  mouth,  225 
cold  packs,  222 
convalescence,   227 
diarrhea,  225 
diet,  220 

diet  of  McCrea,  220 
diet  of  Osier,  220 
diet  of  Shattuck,  220 
hemorrhage,  226 
hydrotherapy,  221 
intestinal  antiseptics,  223 
liquids,  221 
medicinal    antipyretics, 

223 
meteorism,  226 
perforation,   227 
prescriptions,  224-226 
surgery,  227 
tonics,  227 
Inflammatory  rheumatism  (see  In- 
fectious     diseases  —  Rheu- 
matic fever) 
Interstitial  nephritis,  chronic   (see 
Diseases  of  the  kidneys  and 
bladder) 
pneumonia,  chronic  (see  Diseases 
of  the  lungs  and  pleurae) 
Intestines,  diseases  of  the  ( see  Dis- 
eases of  the  intestines) 

J 
Jaundice  (see  Diseases  of  the  liver- 
— Icterus ) 

K 

Kidney,  movable  (see  Diseases  of 
the  kidneys  and  bladder ) 

Kidneys,  diseases  of  the  (see  Dis- 
eases of  the  kidneys  and 
bladder ) 


Lsennec's  cirrhosis  (see  Diseases  of 
the  liver — Portal  cirrhosis) 


INDEX. 


297 


Liver,  abscess  of  the   (see  Diseases 

of  the  liver) 
cancer   of   the    (see   Diseases   of 

the  liver) 
diseases  of  the   (see  Diseases  of 

the  liver) 
Leukemia     (see     Diseases    of    the 

blood) 
Lobar  pneumonia   (see  Diseases  of 

the  lungs  and  pleurae ) 
Lobular  pneumonia    (see   Diseases 

of   the  lungs   and   pleurse — 

Broncho-pneumonia ) 
Lungs,   diseases   of  the    (see   Dis- 
eases    of     the     lungs     and 

pleurse) 
edema   of  the    (see   Diseases    of 

the  lungs  and  pleurse) 

M 

Malaria  (see  Infectious  diseases) 
Malignant    endocarditis    (see   Dis- 
eases  of   the   vascular   sys- 
tem) 
Measles  (see  Infectious  diseases) 
Movable   kidney    (see   Diseases   of 

the  kidneys  and  bladder) 
Mucous  colitis  (see  Diseases  of  the 

intestines ) 
Myxedema     (see    Diseases    of    the 
ductless  glands) 

N 

Nephritis,   acute    (see  Diseases  of 
the  kidneys  and  bladder) 
chronic  interstitial  (see  Diseases 
of  the  kidneys  and  bladder) 
chronic     parenchymatous      (see 
Diseases  of  the  kidneys  and 
bladder ) 
Nephrolithiasis  ( see  Diseases  of  the 
kidneys  and  bladder) 


Obstruction  of  the  bowel  (see  Dis- 
eases of  the  intestines) 


Palpitation    ( see   Diseases   of  the 
vascular  system) 


Pancreas,  carcinoma  of  the  (see 
Diseases  of  the  pancreas  and 
peritoneum ) 
diseases  of  the  (see  Diseases  of 
the  pancreas  and  perito- 
neum) 

Pancreatic  cysts  (see  Diseases  of 
the  pancreas  and  perito- 
neum) 

Pancreatitis,    acute    (see   Diseases 
of  the  pancreas  and  perito- 
neum) 
chronic  ( see  Diseases  of  the  pan- 
creas and  peritoneum) 

Parenchymatous  nephritis,  chronic 
(see  Diseases  of  the  kidneys 
and   bladder ) 

Patient,  physician  and  (see  Gen- 
eral considerations) 

Pectoris,  angina  (see  Diseases  of 
the  vascular  system) 

Pericarditis  (see  Diseases  of  the 
vascular  system) 

Peritoneum,  diseases  of  the  (see 
Diseases  of  the  pancreas  and 
peritoneum ) 

Peritonitis,  acute  (see  Diseases  of 
the  pancreas  and.  perito- 
neum) 

Pernicious  anemia  (see  Diseases  of 
the  blood) 

Physician  and  patient  (see  Gen- 
eral considerations) 

Portal  cirrhosis  (see  Diseases  of 
the  liver) 

Pleurse,  diseases  of  the  (see  Dis- 
eases of  the  lungs  and 
pleurse ) 

Pleurisy,  acute  (see  Diseases  of 
the  lungs  and  pleurse) 

Pneumonia,      chronic     interstitial 
(see   Diseases  of   the   lungs 
and  pleurse) 
lobar  (see  Diseases  of  the  lungs 

and  pleurse) 
lobular     (see    Diseases    of    the 
lungs  and  pleurse — Broncho- 
pneumonia ) 

Pseudoleukemia  (see  Diseases  of 
the  blood) 


298 


INDEX. 


Pulmonary  gangrene   (see  Diseases 
of  the  lungs  and  pleurae) 
tuberculosis  (see  Diseases  of  the 
lungs  and  pleurae) 

Purpura  (see  Diseases  of  the 
blood) 

Pyelitis  (see  Diseases  of  the  kid- 
neys and  bladder) 

R 

Rheumatic  fever  (see  Infectious 
diseases ) 

Rheumatism,  incflammatory  (see 
Infectious  diseases  —  Rheu- 
matic fever) 

S 

Scarlatina  (see  Infectious  diseases 
— Scarlet  fever) 

Scarlet  fever  (see  Infectious  dis- 
eases ) 

Stomach,  diseases  of  the  (see  Dis- 
eases of  the  stomach) 

Suppurative  cholangeitis  (see  Dis- 
eases of  the  gallbladder) 

System,  vascular,  diseases  of  the 
( see  Diseases  of  the  vascular 
Bystem ) 


Tuberculosis,  pulmonary  (see  Dis- 
eases of  the  lungs  and 
pleurae ) 

Typhoid  (see  Infectious  diseases) 

U 

Ulcer,  gastric  (see  Diseases  of  the 
stomach ) 

Uremia  (see  Diseases  of  the  kid- 
neys and  bladder) 


Valvular  diseases  of  the  heart  (see 
Diseases  of  the  vascular  sys- 
tem) 

Vascular  system,  diseases  of  the 
(see  Diseases  of  the  vascu- 
lar system) 

Visceroptosis  (see  Diseases  of  the 
intestines ) 


Yellow   atrophy,    acute    (see    Dis- 
eases of  the  liver) 


